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ONLINE APPENDIX
GLOBAL STRATEGY FOR
ASTHMA MANAGEMENT AND PREVENTION
UPDATED 2020
© 2020 Global Initiative for Asthma
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GLOBAL STRATEGY FOR ASTHMA
MANAGEMENT AND PREVENTION
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2020
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ONLINE APPENDIX
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This online Appendix contains background and supplementary material for the Global Initiative for Asthma
(GINA) 2020 Global Strategy Report for Asthma Management and Prevention. The full GINA report and
other GINA resources are available at www.ginasthma.com
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This document is intended to provide background information for the full GINA 2020 report, as a general
guide for health professionals and policy-makers. It is based, to the best of our knowledge, on current
best evidence and medical knowledge and practice at the date of publication. When assessing and
treating patients, health professionals are strongly advised to consult a variety of sources and to use their
own professional judgment, and to take into account local or national regulations and guidelines. GINA
cannot be held liable or responsible for inappropriate healthcare associated with the use of this
document, including any use which is not in accordance with applicable local or national regulations or
guidelines.
TABLE OF CONTENTS
Chapter 1. The burden of asthma .............................................................................................................................. 7
Prevalence, morbidity and mortality ............................................................................................................................... 7
Social and economic burden ........................................................................................................................................... 9
Reducing the burden of asthma ...................................................................................................................................... 9
Chapter 2. Factors affecting the development and expression of asthma...................................................................11
Background .................................................................................................................................................................... 11
Host factors.................................................................................................................................................................... 12
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Environmental factors ................................................................................................................................................... 13
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Chapter 3. Mechanisms of asthma ...........................................................................................................................19
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Airway inflammation in asthma .................................................................................................................................... 19
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Structural changes in the airways.................................................................................................................................. 23
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Pathophysiology ............................................................................................................................................................ 23
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Special mechanisms in specific contexts ....................................................................................................................... 24
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Chapter 4. Tests for diagnosis and monitoring of asthma ..........................................................................................26
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Measuring lung function................................................................................................................................................ 26
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Non-invasive markers of airway inflammation ............................................................................................................. 29
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Telehealthcare ............................................................................................................................................................... 31
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Chapter 5. Asthma pharmacotherapy ......................................................................................................................33
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Part A. Asthma pharmacotherapy - adults and adolescents ............................................................................................. 33
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Route of administration................................................................................................................................................. 33
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Controller medications .................................................................................................................................................. 33
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Add-on controller medications ...................................................................................................................................... 39
Reliever medications ..................................................................................................................................................... 44
Other medications ......................................................................................................................................................... 45
Complementary and alternative medicines and therapies ........................................................................................... 47
Part B.
Asthma pharmacotherapy – children 6–11 years ............................................................................................. 48
Route of administration................................................................................................................................................. 48
Controller medications .................................................................................................................................................. 49
Add-on controller medications ...................................................................................................................................... 54
Reliever medications ..................................................................................................................................................... 55
Other medications, not recommended for use in children ........................................................................................... 55
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Part C.
Asthma pharmacotherapy – children 5 years and younger .............................................................................. 57
Controller medications .................................................................................................................................................. 57
Reliever medications ..................................................................................................................................................... 60
Chapter 6. Implementing asthma management strategies in health systems ............................................................ 61
Introduction ................................................................................................................................................................... 61
Planning an implementation strategy ........................................................................................................................... 62
Economic value of implementing management recommendations for asthma care ................................................... 67
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GINA dissemination and implementation resources ..................................................................................................... 67
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TABLE OF FIGURES
World map of the prevalence of asthma in adults ........................................................................................... 7
Box A1-2.
Prevalence of current asthma in 2000–2003 in children aged 13–14 years (%) ............................................ 8
Box A2-1.
Factors influencing the development and expression of asthma .................................................................. 11
Box A3-1.
Inflammatory cells in asthmatic airways ........................................................................................................ 19
Box A3-2.
Structural cells in asthmatic airways ............................................................................................................. 21
Box A3-3.
Key cellular mediators in asthma .................................................................................................................. 22
Box A3-4.
Structural changes in asthmatic airways ....................................................................................................... 23
Box A4-1.
Measuring PEF variability ............................................................................................................................. 28
Box A4-2.
Measuring airway responsiveness ................................................................................................................ 29
Box A5-1.
Low, medium and high daily doses of inhaled corticosteroids for adults and adolescents........................... 34
Box A5-2.
Inhaler devices, optimal technique, and common problems for children ...................................................... 49
Box A5-3.
Low, medium and high daily doses of ICS for children 6–11 years .............................................................. 50
Box A5-4.
Corticosteroids and growth in children .......................................................................................................... 51
Box A5-5.
Corticosteroids and bones in children ........................................................................................................... 51
Box A5-6.
Low daily doses of inhaled corticosteroids for children 5 years and younger ............................................... 57
Box A6-1
Examples of barriers to the implementation of evidence-based recommendations ..................................... 62
Box A6-2.
Essential elements required to implement a health-related strategy ............................................................ 62
Box A6-3.
Common asthma management care gaps .................................................................................................... 64
Box A6-4
Examples of high-impact interventions in asthma management .................................................................. 65
Box A6-5
Potential key outcomes and targets to consider for implementation programs ............................................ 66
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Box A1-1.
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Chapter 1.
The burden of asthma
PREVALENCE, MORBIDITY AND MORTALITY
Asthma is a problem worldwide, with an estimated 358 million affected individuals.1 Despite hundreds of reports on the
prevalence of asthma in widely differing populations, the lack of a precise and universally accepted definition of asthma
makes reliable comparison of reported prevalence from different parts of the world problematic.2 Nonetheless, based on
standardized methods for assessing asthma symptoms, it appears that the global prevalence of asthma ranges from 1
to 22% of the population in different countries (Boxes A1-1, A1-2).3-5 There are insufficient data to determine the likely
causes of the described variations in prevalence within and between populations.
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There is firm evidence that international differences in asthma symptom prevalence in children have decreased over
recent decades; symptom prevalence has been decreasing in Western Europe and increasing in regions where
prevalence was previously low.6 Asthma symptom prevalence in Africa, Latin America, Eastern Europe and Asia
continues to rise. The World Health Organization Global Burden of Disease Study estimated that in 2015, 26.2 million
disability-adjusted life years (DALYs) were lost due to asthma, representing 1.1% of the total global disease burden.1 It
is estimated that asthma causes 495,000 deaths worldwide every year,7 with widely varying case fatality rates that may
reflect differences in management.3
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Box A1-1. World map of the prevalence of asthma in adults
Prevalence of ‘clinical asthma’ in adults from the World Asthma Survey, 2003-2005. Figure reproduced with permission from To et al, BMC Pul Med
2012; 12:204. Data based on doctor diagnosed asthma and/or ever treated for asthma and/or taking asthma medication in the last 2 weeks.
GINA Appendix Chapter 1. Burden of asthma
7
Box A1-2. Prevalence of current asthma in 2000–2003 in children aged 13–14 years (%)
% asthma
Country
% asthma
Country
% asthma
15.6
Austria
7.6
Ethiopia
4.6
El Salvador
15.4
Turkey*
7.4
Morocco
4.5
Australia
15.3
Malta
7.3
Malaysia
4.5
Vietnam
14.8
Ukraine
7.3
FYR Macedonia
4.4
Scotland
13.9
Tunisia
7.2
Algeria
4.4
Wales
13.8
Nicaragua
6.9
South Korea
4.4
Costa Rica
13.7
Canada
6.9
Mexico
4.4
New Zealand
13.4
France*
6.8
Hong Kong
4.3
Republic of Ireland
13.4
Norway*
6.8
Palestine
4.3
Channel Islands
13.3
Bolivia
6.8
Philippines
4.2
England
11.5
Trinidad and Tobago
6.6
Sultanate of Oman
4.2
Sri Lanka
11.5
Nigeria
6.5
Croatia
4.2
Panama
11.5
Niue
6.4
Belgium
4.2
Romania
11.4
Sudan
6.3
Bulgaria
4.1
United States of America
11.1
Argentina
6.3
Honduras
11.0
United Arab Emirates*
Reunion Island
10.8
Jordan
Paraguay
10.5
Netherlands
Barbados
10.4
Colombia
Congo
9.9
Portugal
Tokelau
9.9
Singapore
Peru
9.8
French Polynesia
Ivory Coast
9.7
South Africa
9.6
Finland
9.5
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Isle of Man
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Country
4.1
Italy
4.1
6.2
Kyrgyzstan
3.9
6.1
Kuwait
3.8
5.9
Bangladesh*
3.8
5.9
Democratic Republic of
Congo
3.8
5.7
Lithuania
3.7
5.7
Occupied Territory of
Palestine*
3.6
Russia
5.6
Egypt
3.5
Iran
5.4
Taiwan
3.1
Pakistan
5.4
Denmark*
3.0
Cook Islands
5.3
India
2.9
9.3
Spain
5.3
Hungary
2.9
8.9
Latvia
5.3
Samoa
2.9
Germany
8.8
Fiji
5.2
Cameroon
2.9
Togo
8.4
Thailand
5.2
Syrian Arab Republic
2.6
Ecuador
8.3
Gabon
5.1
Indonesia
2.6
Uruguay
8.2
Poland
5.1
Georgia
2.6
Kingdom of Tonga
8.1
Japan
5.0
Switzerland*
2.3
Czech Republic*
8.0
Sweden
4.9
Greece*
1.9
Kenya
7.9
Serbia and Montenegro
4.8
China
1.8
Venezuela
7.7
Estonia
4.7
Albania
1.7
Chile
7.7
Uzbekistan*
4.6
Nepal*
1.5
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Cuba
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Guinéa
9.4
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Brazil
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New Caledonia
6.2
Data are based on ISAAC III.4 The prevalence of current asthma in the 13-14 year age group is estimated as 50% of the prevalence of self-reported
wheezing in the previous 12 months.*No data available from ISAAC III, figures taken from Global Burden of Asthma Report3
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GINA Appendix Chapter 1. Burden of asthma
SOCIAL AND ECONOMIC BURDEN
Social and economic factors are integral to understanding asthma and its care, from the perspective of both the
individual person with asthma and the health care provider. In addition, quantifying the socioeconomic burden of
diseases is important as it provides critical information to decision makers to efficiently allocate scarce health care
resources. Attention needs to be paid to both direct medical costs (identifiable health care services and goods used for
asthma such as hospital admissions, physician visits and medications) and indirect costs (productivity loss and
premature death).8,9
Direct costs
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The monetary costs of asthma, as estimated in a variety of health care systems including those of the United States,10,11
Canada,12 Italy,13 and the United Kingdom14 are substantial. Few economic studies are conducted in non-western
countries, but there is strong evidence that asthma imposes a significant burden in the developing world.15
Exacerbations are major determinants of the direct cost of asthma, and preventing exacerbations should be an
important consideration in asthma management.16
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Indirect costs
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Since asthma is a chronic health condition that affects individuals across all ages, productivity loss due to asthma is
substantial.17 Absence from school and days lost from work are reported as substantial social and economic
consequences of asthma in studies from various regions of the world.9,18 Productivity loss itself can be in the form of
missed work time (absenteeism), and present at work but with reduced performance (presenteeism).19 Very few
comparisons are available, but productivity loss due to presenteeism seems to be a more important source of economic
burden than absenteeism.17
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REDUCING THE BURDEN OF ASTHMA
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Poor asthma control is associated with higher medical costs, increased productivity loss, and substantial reductions in
quality of life.20 In closely controlled clinical trials, good asthma control can be achieved in the majority of patients.21
Nevertheless, in practice there remains a substantial fraction of patients with poorly controlled asthma due to suboptimal treatment. For example, a recent study of pharmacological treatment of asthma in adults from the European
Community Respiratory Health Survey I, II and III found that, although ICS use had increased over 20 years, only onethird of patients with persistent asthma were taking ICS on a regular basis, and fewer than half had seen a doctor for
their asthma in the previous year.22 In low and middle income countries, there are substantial problems with access to
even basic asthma medications.23
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Such findings signify care gaps and potential for improvements in health and reductions in costs.20 However, good
management of asthma poses a challenge for individuals, health care professionals, health care organizations, and
governments. Efforts are required to provide access to appropriate controller medications, and to ensure that they are
prescribed appropriately by health care providers and used correctly by patients.24
Comparisons of the cost of asthma in different regions lead to the following conclusions.
•
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The costs of asthma depend on its prevalence, the individual patient’s level of asthma control, the extent to which
exacerbations are avoided, and the costs of medical care and medications.
Emergency treatment is more expensive than planned treatment and preventing hospitalizations is an achievable
goal for health services.
The non-medical economic costs of asthma are substantial. Specifically, presenteeism seems to be particularly
high in patients with asthma.
The presence of many individuals with uncontrolled asthma signifies a preventable source of socioeconomic
burden
GINA Appendix Chapter 1. Burden of asthma
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Additional information about the burden of asthma can be found in the 2018 Global Asthma Report25 and from the World
Health Organization Global Burden of Disease project (www.who.int/healthinfo/global_burden_disease). Ongoing audit
and research on the social and economic burden of asthma and the cost-effectiveness of treatment are needed in both
developed and developing countries.
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GINA Appendix Chapter 1. Burden of asthma
Chapter 2.
Factors affecting the development and expression of asthma
BACKGROUND
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Box A2-1. Factors influencing the development and expression of asthma
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Allergens
o Indoor: domestic mites, furred animals (e.g.
dogs, cats, mice), cockroaches, fungi
o Outdoor: pollen, molds
Occupational sensitizers and allergens (e.g. flour,
laboratory rodents, paints)
Infections (predominantly viral)
Microbiome
Exposure to tobacco smoke
o Passive smoking
o Active smoking
Outdoor or indoor air pollution
Diet
Stress
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•
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Genetic (e.g. genes predisposing to atopy, airway
hyperresponsiveness, airway inflammation and
innate immunity)
Obesity
Sex
Pre-term or with small size for gestational age
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Environmental factors
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Host factors
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Factors that influence the risk of developing asthma include host and environmental factors (Box A2-1).26 However, the
mechanisms whereby these factors influence the development and expression of asthma are complex and interactive;
for example, genes are likely to interact both with other genes and with environmental factors to determine asthma
susceptibility.27,28 In addition, developmental aspects such as the maturation of the immune response, development of
atopy, and the timing of infectious exposures during the first years of life, are emerging as important factors that modify
the risk of asthma in the genetically susceptible person. Strategies that may be useful to prevent the development of
asthma are described in the Global Strategy for Asthma Management and Prevention 2019, Chapter 7.29
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Links between asthma and socioeconomic status, with a higher prevalence of asthma in developed than in developing
nations; in poor compared with affluent populations in developed nations; and in affluent compared with poor
populations in developing nations; are likely to reflect lifestyle differences such as exposure to allergens, infections, diet,
and access to health care. Much of what is known about risk factors for the development of asthma comes from studies
of young children; the risk factors in adults, particularly de novo in adults who did not have asthma in childhood, are less
well defined.
The heterogeneity of asthma, the previous lack of a clear definition, and lack of a biological ‘gold standard’ marker for
asthma present significant problems in studying the role of different risk factors in the development of this complex
disease. Characteristics that are commonly found in patients with asthma (e.g. airway hyperresponsiveness, atopy and
allergic sensitization) are themselves products of complex gene–environment interactions and are therefore both
features of asthma and risk factors for the development of the disease.
GINA Appendix Chapter 2. Development and expression of asthma
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HOST FACTORS
Genetic
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Asthma has a complex heritable component. Current data show that multiple genes may be involved in the
pathogenesis of asthma,30 and different genes may be involved in different ethnic groups.31 The search for genes linked
to the development of asthma has previously focused on four major areas: production of allergen-specific
immunoglobulin E (IgE) antibodies (atopy); expression of airway hyperresponsiveness; generation of inflammatory
mediators such as cytokines, chemokines and growth factors; and determination of the ratio between T helper
lymphocyte Th1 and Th2 immune responses (as relevant to the hygiene hypothesis of asthma).32 Family studies and
case-control association analyses have identified a number of chromosomal regions that are associated with asthma
susceptibility. For example, a tendency to produce an elevated level of total serum IgE is co-inherited with airway
hyperresponsiveness, and a gene (or genes) governing airway hyperresponsiveness is located near a major locus that
regulates serum IgE levels on chromosome 5q.33 Over the last 10-15 years asthma genetics has moved towards large
scale genome-wide association studies and meta-analyses of these studies.
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A meta-analysis of genome-wide association studies (GWAS) for IgE identified a variant near HLA-DQB1 as a predictor
of total serum IgE levels in multiple race and ethnic groups.34 Another GWAS study defined the potential importance of
genes such as IL33, IL1RL1, IL18R1 and TSLP that are involved in epithelial cell danger signal pathways.35 To further
complicate the issue, researchers have found associations for variants in innate immunity genes with asthma and
suggest that these may play a role, in conjunction with early-life viral exposures, in the development of asthma.36 In the
most recent, large meta-analysis of GWAS of asthma conducted by the Transatlantic Asthma Genetics Consortium
(TAGC),37 nine known asthma loci were confirmed and five new asthma loci were discovered. Several asthma
susceptibility genes appear to code for proteins which are either epithelial alarmins (e.g. IL-33, TSLP), type 2 cytokines
(e.g. IL-5, IL-13) or transcription factors (i.e. GATA3 and RORα) of type 2 lymphocytes (either T helper 2 CD4+
lymphocytes or innate lymphoid cells type 2 [ILC2]).To date most asthma genetics studies have focused on mild-tomoderate disease. The largest moderate-to-severe asthma GWAS has confirmed the importance of the same genes as
described in milder disease but has demonstrated an additional association with the MUC5AC gene implicating a role for
mucin production in more severe disease.38
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In addition to genes that predispose to asthma there are genes that are associated with the response to asthma
treatments. For example, variations in the gene encoding the beta2-adrenoreceptor have been linked to differences in
some subjects’ responses to short-acting beta2-agonists.39 Other genes of interest modify the responsiveness to
corticosteroids40 and leukotriene receptor antagonists.41 Genetic markers will likely become important, not only as risk
factors in the pathogenesis of asthma, but also as determinants of responsiveness to treatment.
In childhood, male sex is a risk factor for asthma. Prior to the age of 14, the prevalence of asthma is nearly twice as
great in boys as in girls.42 As children grow older, the difference in prevalence between the sexes narrows, and by
adulthood the prevalence of asthma is greater in women than in men. The reasons for this sex-related difference are not
clear;43 one potential contributor is differences in lung and airway size, which are smaller in males than in females in
infancy,44 but larger in females in adulthood.45
Early growth characteristics
Early growth characteristics might persistently affect lung function and thereby contribute to the risk of obstructive
respiratory diseases in later life. Younger gestational age, lower birth weight, and greater infant weight gain are
independently associated with persistent changes in childhood lung function. Stratified analyses of birth cohorts have
shown that children born very preterm with a relatively low birth weight had the lowest FEV1 and FEV1/FVC ratio.
Preterm birth, low birth weight, and greater weight gain were all associated with an increased risk of childhood asthma.46
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GINA Appendix Chapter 2. Development and expression of asthma
Obesity
The prevalence and incidence of asthma are increased in obese subjects (body mass index >30 kg/m2), particularly in
women with abdominal obesity.47,48 Inappropriate attribution of shortness of breath may contribute to over-diagnosis, but
one study found that over-diagnosis of asthma was no more common in obese than in non-obese patients.49 It is not
known why asthma develops more frequently in the obese. Potential contributing factors include changes in airway
function due to the effects of obesity on lung mechanics; the development of a pro-inflammatory state in obesity; and an
increased prevalence of comorbidities, genetic, developmental, hormonal or neurogenic influences.48
Depression
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While depression is a common comorbidity of asthma, the temporal relationship between the two conditions has not
been clear. A systematic review and meta-analysis of six prospective studies with follow-up of 8-20 years found that
depression was associated with a 43% increased risk of developing adult-onset asthma, after adjustment for potential
confounding factors such as age, sex, smoking and body mass index. On the other hand, the two studies examining the
relationship between asthma and risk of subsequent depression found no significant association, but this may have
been due to insufficient studies being available.50
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ENVIRONMENTAL FACTORS
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Allergens
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Although indoor and outdoor inhalant allergens are well-known triggers of asthma exacerbations in people with
established asthma, their specific role in the initial development of asthma is still not fully resolved. Birth cohort studies
have shown that sensitization to house dust mite allergens, cat dander, dog dander,51,52 and Aspergillus mold53 are
independent risk factors for asthma-like symptoms in children up to 3 years of age. For children at risk of asthma,
dampness, visible mold and mold odor in the home environment are associated with increased risk of developing
asthma.54 However, the relationship between allergen exposure and sensitization in children is not straightforward,
depending on interactions between the allergen, the dose, the time of exposure, the child’s age, and genetics.
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For some allergens, such as those derived from house dust mites and cockroaches, the prevalence of sensitization
appears to be directly correlated to exposure.52,55 However, while some data suggest that exposure to house dust mite
allergens may be a causal factor in the development of asthma56 other studies have questioned this interpretation.57,58
Cockroach infestation has been shown to be an important cause of allergic sensitization, particularly in inner-city
homes.59
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Some epidemiological studies have found that early exposure to cats or dogs may protect a child against allergic
sensitization or the development of asthma.60-62 Conversely others suggest that such exposure may increase the risk of
allergic sensitization.61,63-65 A study of over 22,000 school-age children from 11 birth cohorts in Europe showed no
association between pets in the home early in the child’s life and higher or lower prevalence of asthma.66
Sensitization to ingestant allergens in early life remains a risk factor for subsequent asthma;67 however, there are
insufficient data to permit intervention, and no strategies can be recommended to prevent allergic sensitization prenatally. In particular, there is no evidence that antenatal peanut or tree nut exposure increases the risk for subsequent
asthma in children.68
Rhinitis in individuals without asthma is a risk factor for development of asthma both in adults and children. In adults,
asthma development in individuals with rhinitis is often independent of allergy; in childhood, it is frequently associated
with allergy.69,70
A meta-analysis of studies examining the effect of allergen immunotherapy concluded that allergen immunotherapy did
not result in a statistically significant reduction in the risk of developing a first allergic disease, but that, among those with
GINA Appendix Chapter 2. Development and expression of asthma
13
allergic rhinitis, there was evidence of a reduced short-term risk of developing asthma. However, it is unclear whether
this benefit was maintained over the longer term.71
Occupational sensitizers
Occupational asthma is asthma caused by exposure to an agent encountered in the work environment.72,73 Asthma is
the most common occupational respiratory disorder in industrialized countries, and occupational agents are estimated to
cause about 15% of cases of asthma among adults of working age.74 Over 300 substances have been associated with
occupational asthma, including highly reactive small molecules such as isocyanates; irritants that may cause an
alteration in airway responsiveness; immunogens such as platinum salts; and complex plant and animal biological
products that stimulate the production of IgE (e.g. flour, laboratory rodents, wood dust). Occupations associated with a
high risk of occupational asthma include bakers, hair dressers, farming and agricultural work, laboratory animal facilities,
painting (including vehicle spray painting), cleaning work, and plastic manufacturing.73
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Most occupational asthma is immunologically mediated and has a latency period of months to years after the onset of
exposure.75 Both IgE-mediated allergic reactions and cell-mediated allergic reactions are involved.76 Levels above which
sensitization frequently occurs have been proposed for many occupational sensitizers; however, the factors that cause
some people but not others to develop occupational asthma in response to exposure to the same agent are not well
identified. Very high exposures to inhaled irritants may cause ‘irritant-induced asthma’ (including reactive airways
dysfunctional syndrome (RADS)) even in non-atopic individuals.77 Atopy and tobacco smoking may increase the risk of
occupational sensitization, but screening individuals for atopy is of limited value in preventing occupational asthma.72
The most important method of preventing occupational asthma is to eliminate or reduce exposure to occupational
sensitizers. However, occupational asthma, once present, persists in most patients even after removal from exposure.72
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Infections
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Infection with a number of viruses during infancy has been associated with the inception of the asthmatic phenotype.
Respiratory syncytial virus (RSV), human rhinovirus (HRV) and parainfluenza virus produce a pattern of symptoms
including bronchiolitis that parallel many features of childhood asthma.78,79 Several long-term prospective studies of
children admitted to hospital with documented RSV infection have shown that approximately 40% will continue to
wheeze or have asthma into later childhood.78,79 On the other hand, some respiratory infections early in life, including
measles and sometimes even RSV, appear to protect against the development of asthma.80 The data do not allow
specific conclusions to be drawn. With the advent of improved molecular techniques for detecting viral pathogens, the
important contributions of community-based wheezing illnesses due to HRV during infancy and early childhood with the
subsequent development of asthma have now been well recognized.81,82 Both allergic sensitization83 and certain genetic
loci84 appear to interact with HRV wheezing illnesses in early life to increase the risk of developing asthma in childhood.
Common bacterial pathogens may also be associated with wheezing illnesses in early life.85 Parasitic infections do not in
general protect against asthma, but infection with hookworm may reduce the risk.86
The ‘hygiene hypothesis’ proposes that exposure to infections early in life influences the development of a child’s
immune system along a ‘non-allergic’ pathway, and leads to a reduced risk of asthma and other allergic diseases.32 This
mechanism may explain observed associations between family size, birth order, day-care attendance, and the risk of
asthma. For example, young children with older siblings and those who attend day care are at increased risk of
infections, but enjoy protection later in life against the development of allergic diseases, including asthma.87-89 The
hygiene hypothesis continues to be investigated.
Recent observations indicate that the microbiome (i.e. the collection of microorganisms and their genetic material), both
within the host and in the host’s surrounding environment, may contribute to the development and/or prevention of
allergic diseases and asthma.90 For example, delivery by cesarean section has been associated with an increased risk
of asthma up to the age of 12 years compared with vaginal delivery.91-93 In rural settings, the prevalence of childhood
asthma is reduced and this has been linked to the presence of bacterial endotoxin in these environments.94 In rural
14
GINA Appendix Chapter 2. Development and expression of asthma
settings, the diversity of microbial exposure in house dust has been correlated inversely with the risk of developing
asthma.95
The interaction between atopy and viral infections appears to be complex in that the atopic state can influence the lower
airway response to viral infections; viral infections can then influence the development of allergic sensitization; and
interactions can occur when individuals are exposed simultaneously to both allergens and viruses.96,97 However, allergic
sensitization in the first 3 years of life is more likely to precede viral-associated wheezing illnesses and may actually be
causal in nature.81 In children with allergic asthma, anti-IgE therapy decreased the duration of rhinovirus infections, viral
shedding, and the risk and severity of rhinoviral illnesses,98 suggesting that in allergic patients, blocking IgE may limit
rhinovirus replication.
Socioeconomic inequalities
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In all communities, poverty is strongly related to ill health. This has not generally been the pattern for asthma, where the
lifetime prevalence of symptoms was usually higher in more affluent societies.99 However, in recent years, data from
many studies have challenged this view. There have been consistent demonstrations of a positive association between
lower socioeconomic status and risk of wheezing, both in high- and in low- and middle-income countries (LMIC),
indicating a more complex interaction between factors, some protective and others causative. In children living in inner
cities in the USA, the burden of asthma is high and appears to be independent of ethnicity and income.100 In addition,
the relationship between poverty and asthma may change over time. For example, a study from Sweden has shown a
reversal of the association between socioeconomic status and asthma prevalence; military conscripts of low
socioeconomic status who three decades ago had the lowest, now have the highest prevalence of asthma, with
increasing prevalence in successive generations.101 In a cohort of Brazilian children, symptoms of asthma have been
associated with unhygienic living conditions and infections.102,103
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Stress
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Asthma prevalence is increased in low income, inner-city neighborhoods, where family stress levels are high.104.
Parental stress, both in the first year of life105 and from birth to early school age,106 has been associated with increased
risk of asthma in school-age children. Lower cortisol levels in response to acute stress are observed in such children,
suggesting a mechanistic explanation for increased asthma prevalence.107 Challenges may be faced by patients with
asthma following large-scale disasters.
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Tobacco smoke
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Exposure to tobacco smoke, either pre-natally108 or after birth,108 is associated with harmful effects including a greater
risk of developing asthma-like symptoms in early childhood. Distinguishing the independent contributions of pre-natal
and post-natal maternal smoking is problematic.109 However, maternal smoking during pregnancy has an influence on
lung development,44 and infants of smoking mothers are four times more likely to develop wheezing illnesses in the first
year of life,109 although there is little evidence that maternal smoking during pregnancy has an effect on allergic
sensitization.110 Exposure to environmental tobacco smoke (passive smoking) also increases the risk of lower
respiratory tract illnesses in infancy111 and childhood.112
In people with established asthma, tobacco smoking is associated with an accelerated decline in lung function;113 may
render patients less responsive to treatment with inhaled114,115 and systemic116 corticosteroids; and reduces the
likelihood of asthma being well controlled.117 In a study of patients with adult-onset asthma, frequent exacerbations in
current or past smokers were associated with higher blood neutrophils, whereas in never-smokers, frequent
exacerbations were associated with higher blood eosinophils.118
GINA Appendix Chapter 2. Development and expression of asthma
15
Outdoor and indoor air pollution
Children raised in a polluted environment have diminished lung function,119 and exposure to outdoor air pollutants has
significant effects on asthma morbidity in children and adults.120-122 Similar associations have been observed in relation
to indoor pollutants (e.g. smoke and fumes from gas or biomass fuels that are used for heating and cooling, molds, and
cockroach infestations).123 Exposure to outdoor pollutants, such as living or attending schools near high-traffic density
roads increased the incidence and prevalence of childhood asthma and wheeze.124,125 Prenatal NO2, SO2, and PM10
exposures are associated with an increased risk of asthma in childhood,126 but it is difficult to separate pre- and postnatal exposure.
Diet
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For some time, the mother’s diet during pregnancy has been a focus of concern relating to the development of allergy
and asthma in the child. There is no firm evidence that ingestion of any specific foods during pregnancy increases the
risk for asthma. However, a recent study of a pre-birth cohort observed that maternal intake of foods commonly
considered allergenic (peanut and milk) was associated with a decrease in allergy and asthma in the offspring.127 Similar
data have been shown in a very large Danish National birth cohort, with an association between ingestion of peanuts,
tree nuts and/or fish during pregnancy and a decreased risk of asthma in the offspring.68,128
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Data suggest that maternal obesity and weight gain during pregnancy pose an increased risk for asthma in children. A
recent meta-analysis of 14 studies129 showed that maternal obesity in pregnancy was associated with higher odds of
ever asthma or wheeze or current asthma or wheeze; each 1 kg/m2 increase in maternal BMI was associated with a 2%
to 3% increase in the odd of childhood asthma. High gestational weight gain was associated with higher odds of ever
asthma or wheeze. However, unguided weight loss in pregnancy should not be encouraged.
L-
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The role of post-natal diet, particularly breast-feeding, in relation to the development of asthma has been extensively
studied and, in general, the data reveal that infants fed formulas of intact cow’s milk or soy protein have a higher
incidence of wheezing illnesses in early childhood compared with those fed breast milk.130
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Vitamin D
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Some data also suggest that certain characteristics of Western diets, such as increased use of processed foods and
decreased antioxidants (in the form of fruits and vegetables), increased omega-6 polyunsaturated fatty acid (found in
margarine and vegetable oil), and decreased omega-3 polyunsaturated fatty acid (found in oily fish) intakes are
associated with recent increases in asthma and atopic disease.131 A systematic review of randomized controlled trials on
maternal dietary intake of fish or long-chain polyunsaturated fatty acids during pregnancy showed no consistent effects
on the risk of wheeze, asthma or atopy in the child.132 One recent study demonstrated decreased wheeze/asthma in preschool children at high risk for asthma when mothers were given a high dose fish oil supplement in the third trimester;133
however ‘fish oil’ is not well defined, and the optimal dosing regimen has not been established.
There has been substantial interest in recent years in the role of vitamin D intake during pregnancy. A systematic review
of cohort, case control and cross-sectional studies concluded that maternal intake of vitamin D, and of vitamin E, was
associated with lower risk of wheezing illnesses in children.134 This was not confirmed in randomized controlled trials of
vitamin D supplementation during pregnancy, although a significant effect was not ruled out.135,136 Evidence is still
inconclusive, and further randomized controlled trials are needed. When the results from these two trials were
combined, there was a 25% reduction of risk of asthma/recurrent wheeze at ages 0-3 years.137 The effect was greatest
among women who maintained 25(OH)vitamin D levels of at least 30ng/ml from the time of study entry through delivery,
suggesting that sufficient levels of Vitamin D during early pregnancy may be important in decreasing risk for early life
wheezing episodes.137
16
GINA Appendix Chapter 2. Development and expression of asthma
Paracetamol (acetaminophen)
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Several epidemiological studies have shown a relationship between frequency of paracetamol use in children or in
pregnancy,138,139 and a diagnosis of asthma in children. Interpretation is confounded by the fact that in infancy,
paracetamol is often administered for viral respiratory infections, which themselves may either contribute to the
development of asthma or be an early manifestation of asthma. In a prospective cohort study, paracetamol use was not
associated with diagnosis of asthma after adjusting for respiratory infections, or when paracetamol was used only for
non-respiratory indications.140 Frequent use of paracetamol by pregnant women has been associated with asthma in
their children,139 but non-causal associations have not been ruled out.141,142
GINA Appendix Chapter 2. Development and expression of asthma
17
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Chapter 3.
Mechanisms of asthma
TE
Asthma is an inflammatory disorder of the airways, which involves multiple inflammatory cells and mediators that
contribute to characteristic clinical and pathophysiological changes.143 In ways that are still not well understood, this
inflammation is strongly associated with early life exposures,144 airway hyper-responsiveness and asthma symptoms.
The underlying mechanisms driving these clinical phenotypes and the response to therapies is incompletely understood.
143,145,146 One major advance has been that biomarkers of type 2 inflammation (such as increased FeNO levels and
blood or sputum eosinophilia), particularly in severe disease, have been shown to predict the therapeutic response to
corticosteroids, monoclonal antibodies targeting type 2 cytokines (e.g. IL5) or their receptors (IL4Rα; IL5R).145,147 There
is a clear need to continue investigation into the root causes of asthma so that targeted diagnostics and therapeutics can
be developed.148
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AIRWAY INFLAMMATION IN ASTHMA
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The clinical spectrum of asthma is highly variable and shows different sputum cellular patterns. Based upon eosinophil
and neutrophil counts in sputum, four asthma inflammatory phenotypes can be discerned: eosinophilic asthma,
neutrophilic asthma, mixed granulocytic asthma and pauci-granulocytic asthma. However, even in patients with paucigranulocytic asthma, the eosinophil count in sputum is still significantly increased as compared with healthy subjects.149
The prevalence of those with eosinophilic or mixed granulocytic is approximately 50-70% although there is variability
between patients. Within patients the proportions change over time and are affected by exposures to allergens, infection
and pollutants and in response to treatment.145 Corticosteroids, even when given acutely for exacerbations, can change
levels of eosinophil biomarkers.150
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In addition to granulocytes other inflammatory cells play key roles in asthma summarized in (Box A3-1)151,152 and their
co-location with structural cells is important such as mast cell airway smooth muscle interactions in airway hyperresponsiveness.145,153 Airway inflammation in asthma persists even when symptoms are episodic, and the relationship
between the severity of asthma and the intensity of inflammation has not been clearly established.154 The inflammation
affects all airways, including the upper respiratory tract and nose in most patients, but its physiological effects are most
pronounced in medium-sized bronchi.
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Cell type
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Box A3-1. Inflammatory cells in asthmatic airways
Action
Release the bronchoconstrictor mediators histamine, cysteinyl leukotrienes and
prostaglandin D2 when activated.155 Mucosal mast cells are activated by allergens and
immunoglobulin E (IgE) through high-affinity IgE receptors as well as by non-allergic
mechanisms including innate immune mechanisms, neural connections and osmotic
stimuli, which accounts for exercise-induced bronchoconstriction.156
Eosinophils
Usually present in increased numbers in asthmatic airways, eosinophils release basic
proteins that may damage airway epithelial cells. They also produce cysteinyl leukotrienes
and growth factors.157 In rare cases of steroid-resistant severe asthma with (sputum or
blood) eosinophilia, an anti-interleukin 5 (IL5) or anti-IL5 receptor antibody can reduce
asthma exacerbations.158-161
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GINA Appendix Chapter 3. Mechanisms of asthma
19
Box A3-1. Inflammatory cells in asthmatic airways (continued)
Cell type
Lymphocytes
Action
Present in increased numbers in asthmatic airways; T helper 2 CD4+ lymphocytes
release specific cytokines, including interkeukins (IL) 4, 5, 9, and 13, which orchestrate
eosinophilic inflammation, mucus overproduction and IgE production by B lymphocytes.162
An increase in Th2 cell activity may be due, in part, to a reduction in the regulatory T cells
that normally inhibit Th2 cells. In severe eosinophilic asthma, there is also an increase in
innate lymphoid cells type 2 (ILC2),163 whereas Th1 and Th17 cells might be involved in
neutrophilic and mixed granulocytic (severe) asthma.162
These professional antigen-presenting cells sample allergens from the airway surface
and migrate to regional lymph nodes where they interact with naïve CD4+ T cells. In
healthy subjects, this dendritic cell (DC) – T cell interaction will induce regulatory T cells
(Treg cells) producing immunomodulatory cytokines such as IL10 and Transforming
Growth Factor beta (TGFβ), whereas in asthmatic individuals the DC -T cell interaction will
ultimately stimulate production of type 2 cytokines by T helper 2 (Th2) cells.164,165 Upon
secondary allergen exposure in sensitized subjects, dendritic cells can activate memory
Th2 cells in the airway mucosa.
Macrophages
Present in increased numbers in asthmatic airways, macrophages may be activated by
allergens through low-affinity IgE receptors to release inflammatory mediators and
cytokines that amplify the inflammatory response, especially in severe asthma.166
These cells are increased in the airways and sputum of some patients with severe
asthma and in smoking asthmatics. The pathophysiological role of these cells is uncertain
and their increase may be elicited by microbial infection of the airways, or even be due to
corticosteroid therapy.167 In patients with severe asthma, neutrophil extracellular traps
(NETs) and extracellular DNA in sputum have been associated with airway epithelial cell
damage and inflammasome activation.168
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Neutrophils
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Dendritic cells
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The characteristic pattern of inflammation that is found in other allergic diseases is also seen in allergic asthma,169 with
activated mast cells, increased numbers of activated eosinophils, and increased numbers of the T-cell receptor invariant,
natural killer T cells and T helper 2 lymphocytes (Th2), which release mediators that contribute to symptoms (Box A3-1).
However, asthma can occur in the absence of allergy to aero-allergens, especially in patients with adult-onset asthma.
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Innate lymphoid cells type 2 (ILC2), regulated by epithelial cell mediators such as TSLP, interleukin (IL)-25 and IL-33,
have also been implicated in airway inflammation in asthma.170 Upon activation by these epithelial alarmins, ILC2 can
produce high amounts of type 2 cytokines (especially IL5 and IL13), leading to eosinophilic airway inflammation (even in
the absence of allergy).171 In some cases (especially severe asthma) neutrophils may also contribute to this response.152
Structural cells of the airways also produce inflammatory mediators, and contribute to the persistence of inflammation in
various ways, as outlined in Box A3-2.
20
GINA Appendix Chapter 3. Mechanisms of asthma
Box A3-2. Structural cells in asthmatic airways
Cell type
Action
These cells sense their environment, express multiple inflammatory
proteins, and release danger signals (alarmins), cytokines, chemokines,
and lipid mediators in response to physical perturbation.121 Viruses and
air pollutants also interact with epithelial cells.
Airway smooth muscle cells
These cells show increased number (hyperplasia), in part due to
proliferation and recruitment of progenitors (fibrocytes and
myofibroblasts),145,172 and size (hypertrophy) In addition to effects on
airway caliber through bronchial dilatation and contraction airway smooth
muscle express similar inflammatory proteins to epithelial cells. 169
Endothelial cells
Endothelial cells of the bronchial circulation play a role in recruiting
inflammatory cells from the circulation into the airway and vascularity is
increased in the airway.173
Fibroblasts and myofibroblasts
These cells produce connective tissue components, such as collagens
and proteoglycans that are involved in airway remodeling and are
associated with the increased airway smooth muscle.
Airway nerves
Cholinergic nerves may be activated by reflex triggers in the airways and
cause bronchoconstriction and mucus secretion. Sensory nerves that
may be sensitized by inflammatory stimuli, including neurotrophins, cause
reflex changes and symptoms such as cough and chest tightness, and
may release inflammatory neuropeptides.
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Airway epithelial cells
GINA Appendix Chapter 3. Mechanisms of asthma
21
Key cellular mediators of asthma
Over 100 different mediators are now recognized to be involved in asthma and mediate the complex inflammatory
response in the airways (Box A3-3).
Box A3-3. Key cellular mediators in asthma
Mediators
Action
Important in the recruitment of inflammatory cells into the airways; mainly
expressed in airway epithelial cells.174 CCL11 (eotaxin), is relatively selective for
eosinophils, whereas CCL17 and CCL22 recruit Th2 cells.
Cysteinyl leukotrienes
Potent bronchoconstrictors and pro-inflammatory mediators mainly derived from
mast cells and eosinophils. They are the only mediators that, when inhibited, have
been associated with an improvement in lung function and asthma symptoms.175
Cytokines
Orchestrate the inflammatory response in asthma and determine its severity.176
Important cytokines include:
• IL-1-beta and TNF-α, which amplify the inflammatory response
• GM-CSF, which prolongs eosinophil survival in the airways
• Th2-derived cytokines, which include
o IL-5, that is required for eosinophil differentiation and survival
o IL-4, that is important for Th2 cell differentiation and IgE expression by B
cells
o IL-13, that is needed for IgE expression, stimulates mucus production by
goblet cells, and induces the enzyme iNOS (inducible Nitric Oxide
Synthase) in airway epithelial cells, leading to increased levels of FeNO
(fraction of exhaled Nitric Oxide [NO]).
Histamine
Released from mast cells, histamine contributes to bronchoconstriction and to the
inflammatory response. Antihistamines however, have little role in asthma
treatment because of their limited efficacy, side-effects, and the apparent
development of tolerance.177
Nitric oxide
A potent vasodilator produced predominantly from the action of inducible nitric
oxide synthase (iNOS) in airway epithelial cells.178
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Chemokines
Prostaglandin D2
A bronchoconstrictor derived predominantly from mast cells. It is involved in Th2
cell recruitment into the airways.
CCL: chemokine ligand; Th2: T helper 2 lymphocytes; IL: interleukin; TNF: tumor necrosis factor; GM-CSF: granulocyte macrophage colony-stimulating
factor.
22
GINA Appendix Chapter 3. Mechanisms of asthma
STRUCTURAL CHANGES IN THE AIRWAYS
In addition to the inflammatory response, characteristic structural changes, often described as ‘airway remodeling’, are
seen in the airways of asthma patients (Box A3-4). Some of these changes are related to the severity of the disease and
may result in relatively irreversible narrowing of the airways.179,180 These changes may represent repair in response to
chronic inflammation, or may occur independently of inflammation.143,181
Box A3-4. Structural changes in asthmatic airways
Tissue
Changes in asthma
A deposition of collagen fibers and proteoglycans under the basement membrane
that is seen in most asthmatic patients, even before the onset of symptoms, but
there is a large overlap with normals. Fibrosis also occurs in other layers of the
airway wall, with deposition of collagen and proteoglycans.131
TE
Subepithelial fibrosis
U
Increased airway
smooth muscle
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A consequence of both hyperplasia and hypertrophy, which contributes to the
increased thickness of the airway wall.179 This process is related to disease
severity, airway luminal narrowing and lung function impairment.
These amplify the influence of growth factors such as vascular endothelial growth
factor, YKL-40 and tissue factor and may contribute to increased airway wall
thickness182 and luminal narrowing.183
Mucus hypersecretion
Results from increased numbers of goblet cells in the airway epithelium and
increased size of sub-mucosal glands184 and is assoaicated with intensity of T2
inflammation.185
IA
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Increased blood
vessels in airway
walls
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PATHOPHYSIOLOGY
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Airway narrowing
Airway smooth muscle contraction: this occurs in response to multiple bronchoconstrictor mediators and
neurotransmitters and is one of the predominant mechanisms of airway narrowing. It is largely reversed by
bronchodilators.
Airway edema: this is due to increased microvascular leakage in response to inflammatory mediators. Airway
edema may be particularly important during acute exacerbations.
Airway thickening: this results from structural changes, often termed ‘remodeling’. Airway thickening is not fully
reversible using current therapies and may be important in more severe disease.
Mucus hypersecretion: a product of increased mucus secretion and inflammatory exudates, mucus hypersecretion
may lead to luminal occlusion (‘mucus plugging’). Charcot-Leyden crystals (CLCs)186 are formed from the
eosinophil granule protein galectin-10 and might contribute to mucus plugging in (severe) eosinophilic asthma.
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Airway narrowing is the final common pathway leading to symptoms and physiological changes in asthma; with airway
narrowing itself likely to be an additional stimulus for remodeling.181 Several factors contributing to the development of
airway narrowing in asthma are listed here.
•
•
•
GINA Appendix Chapter 3. Mechanisms of asthma
23
Airway hyperresponsiveness
Airway hyperresponsiveness, a characteristic functional abnormality of asthma, results in airway narrowing in a patient
with asthma in response to a stimulus that would be innocuous in a healthy person. This airway narrowing leads to
variable airflow limitation and intermittent symptoms. Airway hyperresponsiveness is linked to both inflammation and to
the repair of the airways, and is partially reversible with therapy. The mechanisms of airway hyperresponsiveness are
incompletely understood but include the following.
•
IS
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•
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•
Excessive contraction of airway smooth muscle: this may result from increased volume and/or contractility of
airway smooth muscle cells187,188 amplified by co-location of inflammatory cells, in particular mast cells.153,173
Uncoupling of airway contraction: a result of inflammatory changes in the airway wall that may lead to excessive
narrowing of the airways, and a loss of the maximum plateau of contraction that is found in normal airways when
bronchoconstrictor substances are inhaled.
Thickening of the airway wall: edema and structural changes amplifies airway narrowing due to contraction of
airway smooth muscle for geometric reasons.179
Sensory nerves: these may be sensitized by inflammation, leading to exaggerated bronchoconstriction in
response to sensory stimuli.187
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SPECIAL MECHANISMS IN SPECIFIC CONTEXTS
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O
Exacerbations
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N
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Short-term worsening of asthma may occur as a result of exposure to ‘triggers’ (e.g. exercise, cold air, air pollutants),189
and even certain weather conditions such as thunderstorms in association with grass pollen.190,191 More severe
worsening of asthma usually occurs with viral infections of the upper respiratory tract (particularly rhinovirus and
respiratory syncytial virus)192 and/or allergen exposure.96,97 Infections and allergen exposure increase inflammation in
the lower airways (acute or chronic inflammation) that may persist for several days or weeks.
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Nocturnal asthma
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The mechanisms accounting for the worsening of asthma at night are not completely understood, but may be driven by
circadian rhythms of circulating hormones such as epinephrine, cortisol and melatonin, and neural mechanisms such as
cholinergic tone. The reported nocturnal increase in airway inflammation may reflect a reduction in endogenous antiinflammatory mechanisms.193
PY
Persistent airflow limitation
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O
Some patients with severe or long-standing asthma develop progressive airflow limitation that is not fully reversible with
currently available therapy. This may reflect changes in airway structure or mucus plugging (Box A3-4).185,194 These
patients may be described as having asthma-COPD overlap, or more appropriately as chronic asthma with persistent
airflow limitation. Mechanisms are likely to be heterogeneous. For example, long-term studies suggest that about half of
patients with persistent airflow limitation in adult life reached this position by rapid decline from normal lung function in
early adulthood, whereas the other half had a normal rate of decline from low initial lung function in early adulthood.195
Difficult-to-treat asthma
The reasons why some patients develop asthma that is difficult to manage and relatively insensitive to the effects of
corticosteroids are not well understood.196 Common associations are poor adherence with treatment, incorrect inhaler
technique, (passive or active) smoking and psychological and psychiatric disorders. More information on the
management of difficult-to-treat asthma is provided in the GINA Pocket Guide on Difficult-to-treat & Severe Asthma in
adolescent and adult patients (first version in November 2018; second version in April 2019).197
24
GINA Appendix Chapter 3. Mechanisms of asthma
Probably, genetic factors may contribute in some cases as many of these patients have difficult-to-treat asthma from the
onset of the disease, rather than progressing from milder asthma. In these patients, there may be inflammation of
peripheral airways that leads to airway closure, air trapping and hyperinflation. Although the pathology appears broadly
similar to other forms of asthma, there are more neutrophils, more involvement of small airways, and more structural
changes than in other patients.198
Smoking and asthma
Asthma patients who smoke tobacco have asthma that is more difficult to control, have more frequent exacerbations and
hospital admissions, and experience a more rapid decline in lung function and an increased risk of death than asthma
patients who are non-smokers.199 Asthma patients who smoke may have a neutrophil-predominant inflammation or a
mixed granulocytic inflammation in their airways and are poorly responsive to corticosteroids.114,116
Obesity and asthma
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•
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Mechanical changes
The development of a pro-inflammatory state, with increased production of pro-inflammatory cytokines and
chemokines (e.g. IL6),200 increased oxidative stress, increased leptin and reduced adiponectin levels
An increased prevalence of comorbidities such as gastroesophageal reflux disease, obstructive sleep apnea and
metabolic syndrome200
Shared etiological factors such as common genetic and in utero influences
Dietary and environmental factors.
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Multiple factors may contribute to the increased incidence and prevalence of asthma in obesity,48 including:
D
O
N
O
The use of systemic corticosteroids and a sedentary lifestyle may promote obesity in patients with severe asthma, but in
most instances, obesity precedes the development of asthma.47
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Exercise-induced asthma
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The increased ventilation of exercise results in increased osmolality in airway lining fluid. This triggers surface mast cells
to release mediators such as leukotriene D4, resulting in bronchoconstriction.201 In elite athletes, the long-term effects of
environmental exposures during training may also contribute to the development of airway hyperresponsiveness and
asthma, due to airway epithelium injury, airway inflammatory and structural changes (remodeling). These features have
been observed in elite athletes, even without asthma or airway hyperresponsiveness.201
PY
Aspirin-exacerbated respiratory disease
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This distinct asthma phenotype is associated with intolerance to cyclooxygenase-1 inhibition and increased release of
cysteinyl-leukotrienes due to increased expression of leukotriene C4 synthase in mast cells and eosinophils.202 More
detail is provided in the Global Strategy for Asthma Management and Prevention 2019, Chapter 3, ‘Managing asthma in
specific populations or settings’.29
GINA Appendix Chapter 3. Mechanisms of asthma
25
Chapter 4.
Tests for diagnosis and monitoring of asthma
MEASURING LUNG FUNCTION
The diagnosis of asthma is based on the history of characteristic respiratory symptoms and the demonstration of
variable expiratory airflow limitation (see Global Strategy for Asthma Management and Prevention 2019, Box 1-2).29 A
number of methods are available to assess airflow limitation, but two methods have gained widespread acceptance for
use in patients over 5 years of age. These are spirometry, particularly the measurement of forced expiratory volume in 1
second (FEV1) and forced vital capacity (FVC) and their ratio (FEV1/FVC), and the measurement of peak expiratory flow
(PEF).
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Although measurements of lung function do not correlate strongly with symptoms or other measures of asthma control in
either adults203 or children,204 these measures provide complementary information about different aspects of asthma
control. Patients with asthma frequently have poor perception of the severity of their airflow limitation, especially if their
asthma is long standing.205
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Spirometry
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Spirometry is the recommended method of measuring airflow limitation and reversibility (the latter now also called
bronchodilator responsiveness206) to establish a diagnosis of asthma. Measurements of FEV1 and FVC are made during
a forced expiratory maneuver using a spirometer. Recommendations for the standardization of spirometry have been
published.206 The degree of reversibility in FEV1, that exceeds the variation in a healthy population and is consistent with
a diagnosis of asthma in patients with typical symptoms, is generally accepted as 12% and 200 mL from the prebronchodilator value.45 However most asthma patients, particularly those already on controller treatment, will not exhibit
reversibility at each assessment, and the test therefore lacks sensitivity.207 Repeated testing at different visits, or after
withholding of bronchodilator medications, is advised if confirmation of the diagnosis of asthma is needed.
Recommendations for withholding of bronchodilator medications include 4 hours for SABA, 12 hours for twice-daily
LABA or ICS-LABA, and 24hours for once-daily LABA or ICS-LABA.206
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Between-visit variability in FEV1 of >12% and >200mL has high specificity but poor sensitivity for diagnosis of asthma,208
but it may be more accessible than a bronchial provocation test. Spirometry is effort-dependent, so proper instructions
on how to perform the forced expiratory maneuver must be given to patients in order to obtain reproducible results. The
highest value of three recordings is taken.
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A reduced FEV1 may be found with many other lung diseases (or with poor spirometric technique), but a reduced ratio of
FEV1 to FVC (FEV1/FVC) compared with the lower limit of normal indicates expiratory airflow limitation. In respiratory
literature, the terms ‘airflow limitation’ and ‘airway obstruction’ are often used interchangeably when lung function test
results are being described. Many spirometers now include multi-ethnic age-specific predicted values together with the
lower limit of normal.209 I
Predicted values of FEV1, FVC, and PEF based on age, sex and height have been obtained from population studies.
These are being continually revised, and with the exception of PEF, for which the range of predicted values is too wide,
they are useful for judging whether a given value is likely to be ‘abnormal’ or not. Multi-ethnic reference values have
recently been published for ages 3–95 years.209 The normal range of values is wider in young people (younger than 20
years) and in the elderly (older than 70 years).209
A ‘normal’ or near-normal FEV1 in a patient with frequent respiratory symptoms (especially when symptomatic):
Prompts consideration of alternative causes for the symptoms; e.g. cardiac disease, or cough due to post-nasal drip or
gastroesophageal reflux disease
26
GINA Appendix Chapter 4. Test for diagnosis and monitoring of asthma
In children, FEV1 may be insensitive for diagnosis of mild obstructive disorders. In a meta-analysis of pediatric data,
although isolated lung function measurements were not associated with risk of exacerbations, a decrease in FEV1 of
>10% over a period of 3 months (even within the range of 80% to 120% which is commonly considered as “normal”) was
associated with an increased risk of subsequent exacerbation.210
Peak expiratory flow
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PEF measurements are made using a peak flow meter and can be an important aid in both the diagnosis and monitoring
of asthma. Modern PEF meters are relatively inexpensive, portable, and ideal for patients to use in home settings for
day-to-day measurements of airflow limitation. However, measurements of PEF are not interchangeable with other
measurements of lung function such as FEV1 in either adults or children,211 and FEV1 and PEF expressed as a
percentage of predicted are not equivalent. PEF can underestimate the degree of airflow limitation, particularly as airflow
limitation and gas trapping worsen. Because values for PEF obtained with different peak flow meters vary and the range
of predicted values is wide, PEF measurements should be compared to the patient’s own previous best (‘personal best’)
measurement212 using the same peak flow meter. The personal best measurement is usually obtained while patients are
asymptomatic or on full treatment, and it serves as a reference value for monitoring the effects of changes in treatment.
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Careful instruction is required to reliably measure PEF because PEF measurements are effort-dependent. Most
commonly, PEF is measured first thing in the morning before treatment when values are often close to their lowest, and
then in the afternoon or evening when values are usually higher. On each occasion, the highest of three PEF
measurements should be recorded. Various calculations of PEF variability have been used, including the following:213
PY
For diurnal variability the upper limit of normal with twice-daily PEF measurement is 8% in adults, 9.3% in
adolescents, and 12.3% in healthy children. Diurnal variability is calculated as follows: for each day, calculate the
diurnal variability as [day’s highest PEF minus day’s lowest PEF], divided by the mean of these two values; then
average these daily variability results over 1 week.214
The minimum morning pre-bronchodilator PEF over 1 week, expressed as a percent of the patient’s recent best
(Min%Max) is a simple index for clinical practice (Box A4-1).215
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Which patients should carry out PEF monitoring?
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Short-term PEF monitoring
To confirm the diagnosis of asthma. Although spirometry is the preferred method of documenting variable
expiratory airflow limitation, the following PEF measurements suggest a diagnosis of asthma:
o Improvement in PEF after inhalation of a bronchodilator by 60 L/min or ≥20% from the pre-bronchodilator
value,216 or
o Diurnal variation in PEF of >10% from twice daily readings217 (>20% if calculated from more frequent daily
readings).218
To assess response to treatment
To establish a baseline for management of exacerbations. After starting ICS treatment, personal best PEF (from
twice daily readings) is reached on average within 2 weeks.90 Average PEF continues to increase, and diurnal
PEF variability to decrease, for about 3 months.76,90
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Monitoring of PEF twice daily for 2–4 weeks may be useful in the following contexts:
•
•
Long-term PEF monitoring
Ongoing monitoring of PEF is valuable in a sub-set of patients:
•
To assist in managing the patient’s asthma. This is useful for patients who have limited ability to perceive airflow
limitation,205 or for some patients with severe asthma or frequent or sudden exacerbations. For PEF-based written
asthma action plans, those based on personal best PEF improve asthma outcomes, whereas those based on
predicted PEF do not.219
GINA Appendix Chapter 4. Tests for diagnosis and monitoring of asthma
27
•
To identify environmental (including occupational) causes of asthma symptoms: this involves the patient
monitoring PEF several times each day over periods of suspected exposure to risk factors in the home or
workplace, or during exercise or other activities that may cause symptoms, and also during periods in which they
have no exposure to the suspected agent.
Displaying PEF results on a standardized laterally compressed chart (showing 2 months on a landscape format page)
may improve the accuracy of identification of exacerbations.158 A suitable chart is available to download from
www.woolcock.org.au/moreinfo/.
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Box A4-1. Measuring PEF variability
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The figure shows PEF data of a 27-year old man with long-standing poorly controlled asthma, before and after the start of inhaled
corticosteroid treatment. With inhaled corticosteroid treatment, PEF levels increased, and PEF variability decreased, as seen by the
increase in Min%Max (lowest morning PEF over 1 week/highest PEF over the same week, %).
Measurement of airway responsiveness
For patients who have symptoms consistent with asthma but normal lung function, measuring airway responsiveness to
direct airway challenges (e.g. inhaled methacholine or histamine) or indirect airway challenges (e.g. inhaled mannitol or
an exercise challenge) may help establish a diagnosis of asthma.220 The test results are usually expressed as the
provocative concentration (or dose) of the agonist causing a given fall (often 15% or 20%) in FEV1 (Box A4-2). Recent
guidelines on exercise-induced bronchoconstriction recommend 10% fall in FEV1 as the criterion for a positive exercise
challenge; the authors also noted that a criterion of 15% would provide greater specificity.221
These tests are sensitive for a diagnosis of asthma but have limited specificity; airway hyperresponsiveness has been
described in patients with allergic rhinitis, and in those with airflow limitation caused by conditions other than asthma,
such as cystic fibrosis, bronchiectasis, and chronic obstructive pulmonary disease (COPD).220 Consequently, a negative
28
GINA Appendix Chapter 4. Test for diagnosis and monitoring of asthma
test can be useful to exclude a diagnosis of asthma in a patient who is not taking ICS treatment, but a positive test does
not always mean that a patient has asthma.222
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Box A4-2. Measuring airway responsiveness
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This graph shows airway responsiveness to inhaled methacholine or histamine in a healthy subject, and in a person with asthma who has
mild, moderate or severe airway hyperresponsiveness. People with asthma have both an increased sensitivity to the agonist (as indicated by
FEV1 falling at a lower concentration of agonist), and an increased maximal bronchoconstrictor response to the agonist (as indicated by a
greater fall in FEV1 at a given concentration), compared with those without asthma. Asthma is also characterized by the loss of the plateau in
the response-dose curve that is seen in normal healthy subjects. With direct challenges, the response to the agonist is usually expressed as
the provocative concentration or dose of agonist causing a 20% decrease in FEV1 (PC20 and PD20 respectively).
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Sputum analysis
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NON-INVASIVE MARKERS OF AIRWAY INFLAMMATION
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Airway inflammation may be evaluated by examining spontaneously produced or hypertonic saline-induced sputum for
eosinophilic or neutrophilic inflammation.223,224 Sputum analysis does not assist in the diagnosis of asthma, as sputum
eosinophilia may also be found in eosinophilic bronchitis, COPD and hypereosinophilic syndromes, and asthma may
also have a neutrophilic or mixed inflammatory pattern.167,224 In the ‘future risk’ domain of asthma control, sputum
eosinophilia is associated with an increased risk of exacerbations during corticosteroid reduction or cessation.225-227 In
clinical trials in patients most of whom had moderate to severe asthma, exacerbations were reduced when treatment
was guided by sputum eosinophil percentage.228 However, this test is generally only available in specialized centers,
and careful standardization and training of staff for both sputum induction and cell counting are required for reliable
results.224 There are insufficient data available in children to assess this approach.229
GINA Appendix Chapter 4. Tests for diagnosis and monitoring of asthma
29
Fractional concentration of exhaled nitric oxide
Diagnosis of asthma
Measurement of fractional concentration of exhaled nitric oxide is becoming more widely available. There is a modest
association between blood and sputum eosinophils and FeNO in asthma patients230 and the relationship may vary over
time.231,232 FeNO is usually elevated in non-smokers with eosinophilic asthma who are not taking ICS, and in many
patients with asthma who are taking ICS. Elevated FeNO may also be found in conditions such as allergic rhinitis,
eosinophilic bronchitis and hypersensitivity pneumonitis,233 making it important to consider the context and differential
diagnosis when an elevated FeNO is found. There is ethnic variability in FeNO levels, particularly in children.234 Unlike
sputum eosinophilia, elevated FeNO is generally not predictive of asthma exacerbations during ICS reduction or
cessation.233
Assessment of need for ICS?
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In studies mainly limited to non-smoking patients, FeNO >50 parts per billion (ppb) has been associated with a good
short-term response to ICS.233,235 However, these studies did not examine the longer-term risk of exacerbations. Such
evidence therefore does not mean that it is safe with regard to exacerbations to withhold ICS in patients with low initial
FeNO. More recently, in two 12-month studies in mild asthma, severe exacerbations were reduced with as-needed ICSformoterol versus as-needed SABA and versus maintenance ICS, independent of baseline inflammatory characteristics
including FeNO.236,237
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Consequently, in patients with a diagnosis or suspected diagnosis of asthma, measurement of FeNO can support the
decision to start ICS, but cannot be used to decide against treatment with ICS. Based on past and current evidence,
GINA recommends treatment with daily low-dose ICS or as-needed low dose ICS-formoterol for all patients with mild
asthma, to reduce the risk of serious exacerbations.238
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In children and young adults with asthma, FeNO-guided treatment was associated with a significant reduction in the
number of patients with ≥1 exacerbation (OR 0.67 [95% CI 0.51-0.90]) and in exacerbation rate (mean difference -0.27
[-0.49- -0.06] per year) compared with guidelines-based treatment (Evidence A); similar differences were seen in
comparisons with non-guidelines-based algorithms.239 However, in non-smoking adults with asthma, no significant
reduction was seen in the risk of exacerbations, or in exacerbation rates, with FeNO-guided treatment compared with
guidelines-based treatment.240 In several studies of FeNO-guided treatment, problems with the design of the intervention
and/or control algorithms make comparisons and conclusions difficult.241 Results of FeNO measurement at a single point
in time should be interpreted with caution.233,242
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At present, neither sputum- nor FeNO-guided treatment is recommended for the general asthma population. Sputumguided treatment is recommended for adult patients with moderate or severe asthma who are managed in centers
experienced in this technique243 (Evidence A). However, further studies are needed to identify the populations most
likely to benefit from sputum-guided or FeNO-guided treatment,239,240 and the optimal frequency of FeNO monitoring.
Measurements of allergic status
The presence of atopy or allergic disease such as eczema or allergic rhinitis increases the probability of a diagnosis of
allergic asthma in patients with respiratory symptoms. The identification of specific allergic reactions by skin prick testing
or measurement of a specific immunoglobulin E (IgE) in serum can help identify the factors responsible for triggering
asthma symptoms in individual patients.
Allergy skin prick tests are the primary diagnostic tool for determining a patient’s atopic status. They are simple and
rapid to perform, and have a low cost and high sensitivity. Optimal results are dependent on the use of standardized
allergen extracts and on the skill of the tester.244 The choice of the allergen panel will depend on the local context.
30
GINA Appendix Chapter 4. Test for diagnosis and monitoring of asthma
Measurement of allergen-specific IgE in serum is more expensive and generally less sensitive than skin prick testing for
identifying sensitization to inhaled allergens.244 Measurement of total IgE in serum has no value as a diagnostic test for
atopy, and a normal total IgE does not exclude clinical allergy.244
Provocation of the airways with a suspected allergen or sensitizing agent may be helpful in the setting of occupational
asthma but is not routinely recommended; it is rarely useful in establishing a diagnosis, requires considerable expertise,
and can result in life-threatening bronchospasm.244
In patients with respiratory symptoms, the main limitation of allergy testing is that a positive test does not necessarily
mean that the disease is allergic in nature or that allergy is causing the patient’s asthma. The relevant exposure and its
relationship to the patient’s asthma symptoms must be confirmed by the patient’s history.
TELEHEALTHCARE
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Telehealthcare has been defined as “the provision of personalized healthcare over a distance” with the stipulation that it
comprises of three essential components:245
The patient/carer providing data such as the recording of asthma symptoms, peak flow readings or medication
adherence;
•
These data being transmitted electronically, whether synchronously or asynchronously, to a healthcare provider
who is at some other location; and
•
The healthcare provider then providing personalized feedback that is tailored to the individual.
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Using the above definition, telehealthcare can be considered to encompass an array of technologies, ranging from a
telephone call to short message service (SMS) to video-conferencing to smart peak expiratory flow meters or inhalers,
which connect patients/carers with providers. Telehealthcare is distinct from telemedicine, which is defined as
connecting healthcare providers to each other (e.g. primary care physician to respiratory physician).
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There is increasing policy interest in telehealthcare as it offers the potential for continuous monitoring (as opposed to the
current mainly episodic model of care) and the opportunity for patient-centered delivery of care at home or in an
alternative location of the patient’s choosing.246 In the context of asthma, telehealthcare also offers the opportunity to
support medication adherence, facilitate earlier detection of loss of asthma control and prevent asthma exacerbations.247
However, its implementation and utility are subject to problems such as access and socio-economic disadvantage.248
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There is a growing body of work investigating the effectiveness of telehealthcare interventions, particularly in the context
of managing long-term conditions.249 Much of this work is of relatively poor methodological quality with inconsistent
evidence of impact on clinical or health economic outcomes. The available evidence suggests that simple telephonebased approaches are likely to confer as much benefit as more elaborate remote monitoring-based approaches, and
that these benefits are most likely to be seen in those with moderate-to-severe disease.249
Focusing on asthma, there is evidence that telehealthcare-based approaches can increase the proportion of patients
who are reviewed250 or receive an action plan,251 and can improve adherence,252 but there is no consistent evidence that
these lead to improvement in clinical outcomes such as reduction in symptoms or improvements in asthma-specific
quality of life.250 There is however some evidence from studies, at moderate-to-high risk of bias, that rates of
hospitalization may be reduced over a 12-month period.252 There is very little available evidence on the risks of
telehealthcare or the cost-effectiveness of this approach in the context of managing patients with asthma.253
GINA Appendix Chapter 4. Tests for diagnosis and monitoring of asthma
31
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Chapter 5.
Asthma pharmacotherapy
PART A. ASTHMA PHARMACOTHERAPY - ADULTS AND ADOLESCENTS
ROUTE OF ADMINISTRATION
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Inhaled administration delivers drugs directly into the airways, producing higher local concentrations with significantly
less risk of systemic side effects. Inhaled medications for asthma are available as pressurized metered-dose inhalers
(pMDIs), breath-actuated pMDIs, dry powder inhalers (DPIs), soft mist inhalers, and nebulized or “wet” aerosols. Inhaler
devices differ in their efficiency of drug delivery to the lower respiratory tract, depending on the form of the device,
formulation of medication, particle size, velocity of the aerosol cloud or plume (where applicable), and ease with which
the device can be used by the majority of patients. Individual patient preference, convenience, and ease of use may
influence not only the efficiency of drug delivery but also patient adherence to treatment. Problems with incorrect inhaler
technique are common in community-based studies, regardless of the device, and are associated with worse asthma
control. 254
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Pressurized MDIs (pMDIs) require training and skill to coordinate activation of the inhaler and inhalation. In the past,
medications in pMDIs were dispensed as suspensions in chlorofluorocarbon propellants (CFCs), but most are now
dispensed with hydrofluoroalkane (HFAs) propellant, either as suspensions or as solutions in ethanol. The aerosol
plume of HFA inhalers is generally softer and warmer than that of CFC products.255 For some corticosteroids, the
particle size for HFA aerosols is smaller than for the corresponding CFC product, resulting in less oral deposition (with
associated reduction in oral side effects), and greater lung deposition.255 There are theoretical reasons why smaller
particle ICS could be more effective than larger particle ICS, but methodologic issues with the available studies preclude
a clear answer. A real-world study reported fewer exacerbations with extra-fine vs fine-particle ICS,256 but the analysis
was not adjusted for clustering or for physician characteristics that could have influenced not only the choice of ICS but
also other management decisions relevant to exacerbation outcomes. A meta-analysis found no high-quality evidence of
clinical benefit with fine vs standard particle size ICS.257
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Pressurized MDIs may be used by patients with asthma of any severity, including during exacerbations. However,
patients require training and skill to coordinate activation of the inhaler and inhalation, and this is often easier with use of
a valved spacer. Breath-actuated aerosols may be helpful for patients who have difficulty using conventional pMDIs.255
Dry powder inhalers are generally easier to use than pMDIs, but sufficient inspiratory flow (which varies between
different DPI devices) is required to disaggregate the powder, and this may prove difficult for some patients to generate.
DPIs differ with respect to the fraction of ex-actuator dose delivered to the lung. For some drugs, the dose may need to
be adjusted when switching between different types of devices. Nebulized aerosols are rarely indicated for the treatment
of chronic asthma in adults.258
Some inhaler devices and techniques for their use are illustrated on the GINA website (www.ginasthma.org) and the
ADMIT website (www.inhalers4u.org/).
CONTROLLER MEDICATIONS
Inhaled corticosteroids
Role in therapy
ICS are the most effective anti-inflammatory medications for the treatment of persistent asthma. Studies have
demonstrated their efficacy in reducing asthma symptoms, improving quality of life, improving lung function, reducing the
frequency and severity of exacerbations and reducing asthma mortality,259-265 as well as decreasing airway
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
33
hyperresponsiveness260,266 and controlling airway inflammation.267 However, they do not cure asthma, and when they
are discontinued approximately 25% of patients experience an exacerbation within 6 months.268 Patients not receiving
ICS appear to be at increased risk of airway remodeling and loss of lung function.269,270
ICS differ in their potency and bioavailability,271 but because of relatively flat dose-response relationships in asthma
relatively few studies have been able to confirm the clinical relevance of these differences.272
Box A5-1 lists ‘low’, ‘medium’ and ‘high’ doses of different ICS. It is not a table of equivalence, but represents suggested
total daily doses for the ‘low’, ‘medium’ and ‘high’ dose ICS options. The efficacy of some products varies when
administered via different inhaler devices.273 Doses may be country-specific depending on labelling requirements.
Box A5-1. Low, medium and high daily doses of inhaled corticosteroids for adults and adolescents
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This is not a table of equivalence, but instead, suggested total daily doses for the ‘low’, ‘medium’ and ‘high’ dose ICS
options for adults/adolescents, based on available studies and product information. Data on comparative potency are
not readily available and therefore this table does NOT imply potency equivalence. Doses may be country-specific
depending on local availability, regulatory labelling and clinical guidelines.
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Low dose ICS provides most of the clinical benefit of ICS for most patients with asthma. However, ICS responsiveness
varies between patients, so some patients may need medium dose ICS if their asthma is uncontrolled despite good
adherence and correct technique with low dose ICS (with or without LABA). High dose ICS (in combination with LABA
or separately) is needed by very few patients, and its long-term use is associated with an increased risk of local and
systemic side-effects, which must be balanced against the potential benefits.
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Adults and adolescents (12 years and older)
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Inhaled corticosteroid
200-500
>500-1000
>1000
Beclometasone dipropionate (pMDI, extrafine particle*, HFA)
100–200
>200–400
>400
Budesonide (DPI)
200–400
>400–800
>800
80–160
>160–320
>320
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Beclometasone dipropionate (pMDI, standard particle, HFA)
Total daily ICS dose (mcg) – see notes above
Low
Medium
High
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Ciclesonide (pMDI, extrafine particle*, HFA)
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Fluticasone propionate (DPI)
100
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Fluticasone furoate (DPI)
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Mometasone furoate (DPI)
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Fluticasone propionate (pMDI, standard particle, HFA)
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Mometasone furoate (pMDI, standard particle, HFA)
200
100–250
>250–500
>500
100–250
>250–500
>500
200
400
200-400
>400
DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant; ICS: inhaled corticosteroid; n.a. not applicable; pMDI: pressurized metered dose inhaler
(non-chlorofluorocarbon formulations); ICS by pMDI should preferably be used with a spacer. *See product information.
Most of the clinical benefit from ICS is seen at low doses, and clear evidence of dose-response relationships is seldom
available within the dose ranges evaluated for regulatory purposes. ‘High’ doses are arbitrary, but for most ICS are
those that, with prolonged use, are associated with increased risk of systemic side-effects.
For new preparations, including generic ICS, the manufacturer’s information should be reviewed carefully; products
containing the same molecule may not be clinically equivalent. For more detailed discussion see Raissy et al.271
34
GINA Appendix Chapter 5. Pharmacology. Part A. Adults and adolescents
Most of the benefit from ICS is achieved in adults at relatively low doses, equivalent to 400 mcg of budesonide per
day.274 Post-hoc analysis of a large 3-year randomized controlled trial in patients with mild recent-onset asthma264
showed that the risk of serious exacerbations was halved with low dose ICS even in patients with infrequent symptoms
at entry (0-1 days/week).275 Increasing to higher doses provides little further benefit in terms of asthma control but
increases the risk of side effects.274,276 However, there is marked individual variability of responsiveness to ICS, at least
partly due to heterogeneity of airway inflammation. Because of this and the recognized poor adherence to treatment with
ICS, some patients will require higher ICS doses to achieve full therapeutic benefit.21 Tobacco smoking reduces the
responsiveness to ICS, so higher doses may be required in patients who smoke.115
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For patients whose asthma is not well-controlled on ICS alone, despite good adherence and correct inhaler technique,
add-on therapy with a long-acting beta2-agonist (LABA, see below) is preferred over increasing the dose of
ICS.21,261,277,278 For maintenance treatment, there is a relationship between the dose of ICS and the prevention of severe
exacerbations of asthma,261 although there may be differences in response according to clinical or inflammatory
phenotype.279 Therefore, some patients with severe asthma may benefit from long-term treatment with higher doses of
ICS.
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Adherence with ICS in the community is very poor, exposing the patient to the risks of SABA-only treatment. The
likelihood of good adherence should be checked before prescribing ICS with as-needed SABA.
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Adverse effects
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Local adverse effects from ICS include oropharyngeal candidiasis, dysphonia, and (occasionally) coughing from upper
airway irritation.280 For pressurized MDIs the prevalence of these effects may be reduced by using a spacer device.281
Mouth washing (rinsing with water, gargling, and spitting out) after inhalation may reduce oral candidiasis.281 The use of
pro-drugs that are activated in the lungs but not in the pharynx (e.g. ciclesonide and HFA beclometasone) and new
formulations and devices that reduce oropharyngeal deposition may reduce such effects. The use of ICS may be
associated with periodontal disease, but effects may be confounded by comorbidities, asthma severity, and use of
(highly acidic) salbutamol.282 There is also a strong association between periodontal disease and emergency
department visits and hospitalizations for asthma.282
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ICS are absorbed from the lung, accounting for some degree of systemic bioavailability. The risk of systemic adverse
effects from an ICS depends upon its dose and potency, the delivery system, systemic bioavailability, first-pass
metabolism (conversion to inactive metabolites) in the liver, and the half-life of the fraction of systemically absorbed drug
(from the lung and possibly gut).271 Therefore, the systemic effects differ among the various ICS. Evidence suggests that
in adults, systemic effects of ICS are not a problem at doses of 400 mcg or less of budesonide or equivalent daily.283
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Use of a questionnaire for patient-reported symptoms provides evidence of many more, predominantly mild, dosedependent effects of ICS use,204,205 underlining the need to step down treatment to the lowest dose that maintains good
symptom control and prevents exacerbations.284-286
The systemic side effects of long-term treatment with high doses of inhaled corticosteroids include easy bruising,287
adrenal suppression288-290 and decreased bone mineral density.291 A meta-analysis indicated that, among patients with
asthma, adrenal insufficiency was less common after use of ICS (6.8% of patients) than oral and other forms of
corticosteroids (43.7% of patients). For ICS, the proportion of patients with adrenal insufficiency was higher with
increasing dose (1.5% for low, 5.4% for medium, 18.5% for high dose) and with increasing duration (1.3% for short,
9.0% for medium and 20.3% for long duration treatment).292 The threshold to test corticosteroid users for adrenal
insufficiency should be low in clinical practice, especially for patients with nonspecific symptoms after cessation of
corticosteroid treatment.292 A meta-analysis of case-control studies of non-vertebral fractures in adults using ICS
indicated that in older adults, the relative risk of non-vertebral fractures increased by about 12% for each 1000 mcg/day
(BDP equivalent) increase in the dose, but that the magnitude of this risk was considerably less than other common risk
factors for fracture in the older adult.293 ICS have also been associated with cataracts in cross-sectional studies, 294-296
but there is no evidence of posterior-subcapsular cataracts in prospective studies.297,298 Even at high doses, ICS do not
appear to increase the risk of glaucoma.295,299 One difficulty in establishing the clinical significance of such adverse
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
35
effects lies in dissociating the effect of high dose ICS from the effect of courses of oral corticosteroids taken by patients
with severe asthma.
Exposure to high doses of ICS may increase the risk of tuberculosis, particularly in regions with high prevalence of
tuberculosis.300,301 However ICS are not contraindicated in patients with active tuberculosis.302 A recent case control
study found that people with asthma using ICS have an increased risk of pneumonia or lower respiratory infection when
compared with asthmatics who did not have a prescription for an ICS in the last three months.303 The risk is greater at
higher ICS doses, and may vary between different ICS.303 In a meta-analysis of clinical trials, the risk of adverse or
serious adverse events reported as pneumonia for people with asthma receiving budesonide was not increased
compared with placebo.304 A meta-analysis found no significant difference in the risk of pneumonia between children
receiving ICS and placebo.305
ICS-LABA combinations
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Role in therapy – Steps 1 and 2
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L-
D
O
N
O
T
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O
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O
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U
Low dose ICS-formoterol, used as needed for symptom relief, is a preferred controller treatment in mild asthma. A large
double-blind study in mild asthma found a 64% reduction in severe exacerbations compared with SABA-only
treatment,306 with a similar finding in an open-label study in patients with mild asthma previously taking SABA alone.236
(Evidence A). Two large double-blind studies in mild asthma showed as-needed budesonide-formoterol was non-inferior
for severe exacerbations compared with regular ICS.306,307 In two open-label randomized controlled trials, representing
the way that patients with mild asthma would use as-needed ICS-formoterol in real life, as-needed budesonideformoterol was superior to maintenance ICS in reducing the risk of severe exacerbations236,237 (Evidence A). In all four
studies, the as-needed ICS-formoterol strategy was associated with a substantially lower average ICS dose than with
maintenance low dose ICS. The existing data for as-needed ICS-formoterol are with budesonide-formoterol, but
beclometasone-formoterol should be able to be used in a similar way, as its efficacy in maintenance and reliever therapy
has been established.308 The safety of as-needed ICS-formoterol has been well established in studies of maintenance
and reliever therapy 309,310, and no new safety issues emerged during the recent studies in mild asthma.236,237,306,307
ER
Role in therapy – Steps 3-5
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In patients prescribed regular maintenance ICS, when a low dose of ICS alone fails to achieve good control of asthma,
addition of LABA is the preferred option, preferably as a combination ICS-LABA inhaler. The addition of LABA to ICS
improves clinical asthma outcomes and reduces the number of exacerbations in patients ≥12 years old.261,311-320 In very
large studies in adults and adolescents, severe exacerbations were reduced by 17-21% with maintenance ICS-LABA
combination vs the same dose of ICS, but differences in symptom control and SABA use were small.278,318,319
C
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PY
Controlled studies have shown that delivering ICS and LABA in a combination inhaler is as effective as giving each drug
separately.321 Fixed combination inhalers are more convenient for patients, may increase adherence compared with
using separate inhalers,322 and ensure that the LABA is always accompanied by ICS. Severe exacerbations requiring
hospitalization are more common in patients prescribed separate ICS and LABA inhalers than in those receiving
combination ICS-LABA, likely because of differential adherence.323
Low dose combination inhalers containing the rapid-acting beta2-agonist formoterol with either budesonide or
beclometasone may be used for both maintenance and reliever therapy,308,324,325 to further reduce the risk of
exacerbations in at-risk adult and adolescent patients. When budesonide-formoterol was used as the reliever medication
by patients receiving maintenance budesonide-formoterol, both components contributed to enhanced protection from
severe exacerbations compared with SABA as reliever.326 In patients with a history of one or more severe exacerbations
in the previous year, this strategy provides a reduction in exacerbations and similar improvements in asthma control at
relatively low doses of ICS compared with conventional maintenance therapy with ICS or ICS-LABA.324 In open-label
studies without a requirement for a history of exacerbations, maintenance and reliever therapy was associated with a
similar risk of exacerbations as maintenance ICS-LABA plus as-needed SABA, with a lower average ICS dose.327
36
GINA Appendix Chapter 5. Pharmacology. Part A. Adults and adolescents
A study by Papi et al supports maintenance ICS-LABA, rather than as-needed ICS-formoterol alone (without
maintenance therapy) in Step 3.328 In this study, patients with asthma were eligible if their asthma was either not
controlled by low dose ICS (≤500 mcg BDP/day or equivalent) or if their asthma was controlled by twice-daily
maintenance low-dose ICS+LABA over the previous 2 months. Study participants then entered a 6-week run-in period,
during which they received twice daily open-label combination inhaled budesonide-formoterol 200/6 mcg plus as-needed
inhaled 500 mcg terbutaline. Participants whose asthma was controlled during the final 14 days of the run-in were
randomly allocated to receive either as-needed budesonide-formoterol 200/6 mcg or twice-daily budesonide-formoterol
200/6 mcg. The study found that as-needed ICS-formoterol was inferior to twice-daily ICS-formoterol when assessed by
a composite endpoint of treatment failure. Nearly all of this difference was driven by lower risk of ≥2 nocturnal
awakenings on 2 consecutive days (10% v 21%) with twice-daily therapy. Exacerbations requiring systemic
corticosteroids or ICS for asthma worsening were not different between groups (13 vs. 14%).328
Currently approved combination ICS-LABA inhalers for maintenance treatment in asthma at Steps 3–5 include:
R
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Beclometasone-formoterol
Budesonide-formoterol
Fluticasone furoate-vilanterol trifenoate (once daily)
Fluticasone propionate-formoterol.
Fluticasone propionate-salmeterol
Mometasone-formoterol.
O
•
•
•
•
•
•
T
C
O
Beclometasone-formoterol
Budesonide-formoterol.
O
•
•
PY
Currently approved low dose combination ICS-LABA inhalers for maintenance and reliever treatment in asthma include:
R
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H
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IA
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D
O
N
Earlier studies showed that LABAs may provide longer protection for exercise-induced bronchoconstriction than SABAs,
but the duration of effect wanes with long-term use in adults329 and adolescents.330 Salmeterol and formoterol provide a
similar duration of bronchodilation and protection against bronchoconstrictor agents, but there are pharmacological
differences between them: formoterol has a more rapid onset of action than salmeterol331,332 which may make formoterol
suitable for symptom relief as well as symptom prevention.333 However, LABAs including formoterol and salmeterol, are
indicated in asthma only when given in addition to ICS, preferably in a combination inhaler. For pre-exercise use in
patients with mild asthma, a 6-week study showed that use of low dose budesonide-formoterol for symptom relief and
before exercise reduced exercise-induced bronchoconstriction to a similar extent as regular daily low dose ICS with
SABA for symptom relief and before exercise.334 This suggests that patients with mild asthma who are prescribed asneeded ICS-formoterol do not need to also be prescribed a SABA puffer for pre-exercise use.
C
O
PY
Based on product information, the maximum recommended dose of ICS-formoterol in a single day is a total of 48 mcg
formoterol for beclometasone-formoterol (total 8 inhalations of 100/6 mcg beclometasone-formoterol), and 72 mcg
formoterol for budesonide-formoterol (total 12 inhalations of 200/6 budesonide-formoterol by Turbuhaler). However, in
the randomized controlled trials in mild asthma, such high usage was rarely seen, and average use of as-needed ICSformoterol was around 3-4 doses per week.236,237,306,307
Adverse effects
Adverse effects of ICS are described on p.35. Therapy with LABAs may be associated with headache or cramps, but
systemic adverse effects such as cardiovascular stimulation, skeletal muscle tremor, and hypokalemia, are less
common than with oral beta-agonist therapy. The regular use of beta2-agonists in both short- and long-acting forms may
lead to relative refractoriness to beta2-agonists.335 Based on data indicating a possible increased risk of asthma-related
death associated with the use of salmeterol in a small number of individuals,336 and increased risk of exacerbations
when LABA is used regularly as monotherapy,337 LABAs should never be used as a substitute for inhaled or oral
corticosteroids, and should only be used in combination with an appropriate dose of ICS as determined by a physician,
preferably in a single inhaler.338,339 In the past there had been concerns that using LABA alone or in combination with
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
37
ICS might increase asthma mortality.340,341 However, large randomized controlled trials with ICS-LABA combination
maintenance treatment showed no inferiority to ICS alone for serious adverse events (death, intubation and
hospitalization due to asthma).278,318-320 Based on these studies278,318-320, systematic reviews of randomized controlled
trials338,339 and observational studies,342 LABA is considered safe when used in combination with ICS.343.
No influence of beta2-adrenergic receptor phenotypes upon the efficacy or safety of ICS-LABA therapy has been
observed in adults whether by the single inhaler for maintenance and reliever regimen or at a regular fixed dose.344,345
Leukotriene modifiers
Role in therapy
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Leukotriene modifiers include cysteinyl-leukotriene 1 (CysLT1) receptor antagonists (LTRA) (montelukast, pranlukast,
and zafirlukast) and a 5-lipoxygenase inhibitor (zileuton). Clinical studies have demonstrated that leukotriene modifiers
have a small and variable bronchodilator effect, reduce symptoms including cough,346 improve lung function, and reduce
airway inflammation and asthma exacerbations.347 They may be used as an alternative treatment for adult patients with
mild persistent asthma,348-350 and some patients with aspirin-sensitive asthma respond well to leukotriene modifiers.351
However, when used alone as controller therapy, the effect of leukotriene modifiers are generally less than that of low
doses of ICS, and, in patients already on ICS, leukotriene modifiers cannot substitute for this treatment without risking
the loss of asthma control.352
N
O
T
C
O
PY
O
Leukotriene modifiers used as add-on therapy may reduce the dose of ICS required by patients with moderate to severe
asthma.353 For patients with persistent asthma and with suboptimal asthma control with daily use of ICS, the addition of
anti-leukotrienes is beneficial for reducing moderate and severe asthma exacerbations and for improving lung function
and asthma control compared with the same dose of ICS.354 However, leukotriene modifiers are less effective than
LABA as add-on therapy.355
D
O
Adverse effects
C
O
PY
R
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H
TE
D
M
AT
ER
IA
L-
Leukotriene modifiers are well tolerated, and few if any class-related effects have so far been recognized. Zileuton has
been associated with liver toxicity356 and monitoring of liver tests is recommended during treatment with this medication.
Prescribing information for the use of zileuton should be consulted. No association has been found between ChurgStrauss syndrome and the use of leukotriene modifiers after controlling for asthma drug use, although it is not possible
to rule out an association given that Churg-Strauss syndrome is very rare and highly correlated with asthma severity.357
Post-marketing surveillance reports have led to concerns about a possible association between leukotriene receptor
antagonist use and suicide risk in young adults, but a case-control study found no association after adjustment for
potential confounding factors.358 Patients should be counselled about the risk of neuropsychiatric events with
montelukast and health professionals should consider the benefits and risks of mental health side effects before
prescribing. (ref https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-boxed-warning-about-seriousmental-health-side-effects-asthma-and-allergy-drug).
Chromones: sodium cromoglycate and nedocromil sodium
Role in therapy
The role of sodium cromoglycate and nedocromil sodium in long-term treatment of asthma in adults is limited. Their antiinflammatory effect is weak and they are less effective than low-dose ICS.359 Meticulous daily cleaning of the inhalers is
required to avoid blockage.
Adverse effects
Side effects are uncommon and include cough upon inhalation and pharyngeal discomfort. Some patients find the taste
of nedocromil sodium unpleasant.
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GINA Appendix Chapter 5. Pharmacology. Part A. Adults and adolescents
ADD-ON CONTROLLER MEDICATIONS
Long-acting anticholinergics (also called long-acting antimuscarinics, LAMA)
Role in therapy
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O
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O
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The long-acting anticholinergic, tiotropium has been studied in adolescents and adults with uncontrolled asthma in a
variety of contexts: added to ICS compared with doubling the dose of ICS or adding salmeterol,360 and added to ICS361
or to ICS-LABA with or without other controllers362,363 compared with adding placebo362,363.364 Comparable bronchodilator
effects to salmeterol have been shown in patients with the B16-Arg/Arg genotype, with no significant changes in asthma
control.365 In an open-label genotype-stratified study comparing the addition of LABA or tiotropium in African American
patients receiving ICS, no differences were seen in time to first asthma exacerbation or measures of asthma control
regardless of B16 genotype.345 A Phase II study showed that adding tiotropium to patients with asthma not wellcontrolled on ICS and LABA improved lung function but not symptoms.362 Two large one-year replicate trials in patients
with at least one severe exacerbation in the previous year confirmed improvements in lung function, and also showed a
21% reduction in the risk of a severe exacerbation and 31% reduction in risk of asthma worsening, but inconsistent
improvement were seen in symptom control and quality of life.363 Direct evidence of LAMA versus LABA as add-on
therapy to low dose ICS for Step 3 or medium dose ICS for Step 4 is currently limited to studies of less than six months’
duration comparing tiotropium (Respimat) to salmeterol. Given the much larger evidence base for adding LABA vs
placebo when asthma is not well-controlled on ICS alone, the current evidence is not strong enough to say that LAMA
can be substituted for LABA as add-on therapy; but it may be an alternative option in patients with LABA sideeffects.366,367
T
Adverse effects
IA
L-
D
O
N
O
The safety of tiotropium in these studies, with all patients also taking ICS, was similar to that of salmeterol.360,362,363 Dry
mouth, a characteristic side effect of this class of medication, was reported by fewer than 2% of the patients. There are
no published long-term data (>1 year) on tiotropium safety in asthma.
ER
Anti-IgE
M
AT
Role in therapy
PY
R
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D
Anti-immunoglobulin E (anti-IgE, omalizumab) is a treatment option for patients aged ≥6 years with severe persistent
allergic asthma, with typical criteria including that asthma is uncontrolled on treatment with corticosteroids
(moderate/high dose inhaled and/or oral) and LABA.368,369 The dose of omalizumab is based on serum IgE and patient
weight, with the criteria for dose and eligibility varying between regulatory authorities.
C
O
Anti-IgE therapy is expensive and requires regular subcutaneous injections every 2-4 weeks, and observation after each
injection. Therefore, it should only be considered when common causes of uncontrolled asthma, including incorrect
inhaler technique and poor adherence, have been checked and addressed, and the contribution of comorbidities and
modifiable risk factors to respiratory symptoms and exacerbations has been identified and minimized. For more details,
see GINA Pocket Guide on Difficult-to-Treat and Severe Asthma in Adults and Adolescents.197
Asthma outcomes
Patients may benefit by having fewer exacerbations and need for lower doses of OCS, with modest improvement in
quality of life and in asthma symptom control as reflected by fewer symptoms and less need for reliever medications.368
The efficacy of omalizumab is supported by evidence from many real-life studies.370 A meta-analysis of treatment
outcomes in 25 uncontrolled non-randomized real-life studies examined outcomes at 4-6, 12 and 24 months of treatment
in patients who were symptomatic on ICS plus LABA. Despite marked heterogeneity of patients and clinical sites, the
analysis found improvements in symptom control (ACQ), quality of life (AQLQ), lung function, exacerbations and
hospitalizations, reductions in doses of ICS, and overall assessment of benefit (Global Evaluation of Treatment
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
39
Effectiveness score).370 A long-term prospective cohort study showed improvements in symptom control and work,
school and activity impairment over 5 years.371
In one study, the reduction in severe exacerbations with omalizumab compared with placebo was greatest in patients
with higher baseline blood eosinophil levels (≥260 eosinophils/μL), higher baseline FeNO (≥24 ppb), or higher baseline
periostin level (≥53 ng/mL) while taking high dose ICS.372,373 If a patient does not respond clinically within 4 months of
initiating treatment, it is considered unlikely that further administration of omalizumab will be beneficial.243 Of patients
with a good clinical response to omalizumab, about half relapse if it is discontinued, at a median of 13 months after
discontinuation.374 One placebo-controlled withdrawal study suggested that a high blood eosinophil count prior to
omalizumab withdrawal or an increase in FeNO at 12 weeks after withdrawal may be associated with greater risk of
post-withdrawal exacerbation.375 Studies are needed to evaluate stretching the interval between doses.
Other outcomes
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Nasal polyposis is not a specific indication for therapy with omalizumab, but patients with severe allergic asthma with
concomitant chronic rhinosinusitis with nasal polyposis (CRSwNP) demonstrated a moderate improvement in nasal
polyp score with add-on treatment with omalizumab.376
PY
O
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D
IS
T
In one study in children and adolescents, add-on omalizumab started 4-6 weeks prior to return to school was associated
with fewer fall-time exacerbations than with add-on placebo; there was no difference between omalizumab and ICS
boost.377,378 Analysis demonstrated a reduction in the duration and peak level of viral shedding during rhinoviral infection,
and had a modest impact on frequency and severity of rhinovurus illnesses.98
C
O
Adverse effects
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IA
L-
D
O
N
O
T
Anti-IgE appears to be safe as add-on therapy,368 including in inner-city children generally considered to be at high risk
for exacerbations.379 Injection site reactions are more common with omalizumab than placebo.368 In a systematic review
and meta-analysis of 12 studies, there was no significant increase in risk of malignancy with omalizumab treatment.380
Monitoring of patients receiving omalizumab showed no significant difference in cardiovascular or cerebrovascular
events over 5 years compared with patients not receiving omalizumab, after adjustment for known confounding factors
including OCS use.381 Withdrawal of corticosteroids facilitated by anti-IgE therapy has led to unmasking the presence of
Churg-Strauss syndrome in a small number of case reports.382 Clinicians should be aware of the potential for this to
occur and monitor patients closely.
H
Anti-IL5/5R treatments
R
IG
Role in therapy
C
O
PY
Interleukin 5 (IL-5) is a Type 2 cytokine that is required for eosinophil maturation and survival. Antibody therapies
directed at IL-5 or its receptor are a treatment option for patients with severe eosinophilic asthma whose asthma is
uncontrolled on treatment with corticosteroids (moderate/high dose inhaled +/- oral) and LABA (or another controller).
Three therapies have been approved by one or more major regulators for patients with severe eosinophilic asthma:
mepolizumab and reslizumab, which are monoclonal anti-IL5 antibodies, and benralizumab, which is a monoclonal antiIL5 receptor α antibody.
These medications are expensive, so they should only be considered when common causes of uncontrolled asthma,
including incorrect inhaler technique and poor adherence, have been checked and addressed, and the contribution of
comorbidities and modifiable risk factors to respiratory symptoms and exacerbations has been identified and minimized.
There is debate over the optimal blood eosinophil criterion for patient selection. This report does not state specific
criteria for eligibility for biologic therapies, as these vary between countries and jurisdictions. For more details, see GINA
Pocket Guide on Difficult-to-Treat and Severe Asthma in Adults and Adolescents.197
40
GINA Appendix Chapter 5. Pharmacology. Part A. Adults and adolescents
Asthma outcomes
Mepolizumab: for patients aged ≥12 years, administered monthly (100 mg) by subcutaneous injection. In clinical trials of
patients with severe eosinophilic asthma and two or more severe exacerbations in the previous year, mepolizumab
reduced exacerbations by ~55% compared with placebo.383,384 The reduction in exacerbations was greater with
increasing baseline blood eosinophil count and increasing number of exacerbations in the previous year; no significant
reduction in exacerbations was seen with baseline blood eosinophils <150/μL.385 Modest improvements were seen in
lung function and asthma symptom control.383,384 In patients requiring maintenance OCS, mepolizumab allowed a
reduction in median OCS dose by ~50% compared with placebo, with reduced exacerbations and improved symptom
control.160
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Reslizumab: for patients aged ≥18 years, administered monthly (3 mg/kg body weight) by intravenous infusion. In clinical
trials of patients with uncontrolled asthma symptoms despite moderate-high dose ICS, at least one severe exacerbation
in the previous year, and baseline blood eosinophils of ≥400/μL, reslizumab led to ~50% reduction in moderate or
severe exacerbations compared with placebo, with a modest improvement in lung function and small improvement in
symptom control.386 Reslizumab produced greater reductions in asthma exacerbations and larger improvements in lung
function in patients with late versus early-onset asthma.387
D
O
N
O
T
C
O
PY
O
R
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IS
T
Benralizumab: for patients aged ≥12 years, administered 8-weekly (30mg, first 3 doses 4-weekly) by subcutaneous
injection. In clinical trials of patients with severe eosinophilic asthma, with blood eosinophils ≥300/µL in the previous 12
months while taking high dose ICS+LABA, and ≥2 severe exacerbations in the previous year, benralizumab reduced
exacerbations by ~35-50% and improved lung function, compared with placebo.388 Modest improvements in asthma
symptoms were seen in some groups.388 In patients requiring maintenance oral corticosteroids, benralizumab allowed a
significant reduction in OCS dose compared with placebo, while also reducing exacerbations.161 In patients with mild to
moderate persistent asthma receiving low/medium dose ICS or low dose ICS-LABA, there was no clinically-important
benefit for pre-bronchodilator FEV1 with add-on benralizumab over 12 weeks compared with placebo.389
L-
Other outcomes
M
AT
ER
IA
Nasal polyposis is not a specific indication for therapy with anti-IL5/5R, but patients with severe allergic asthma with
concomitant chronic rhinosinusitis with nasal polyposis (CRSwNP) demonstrated a moderate improvement in nasal
polyp score with add-on treatment with reslizumab or high dose mepolizumab.376
TE
D
Adverse effects
C
O
PY
R
IG
H
Adverse effects are infrequent; they include injection site reactions for mepolizumab, myalgia with reslizumab and
headache with benralizumab. Anaphylactic reactions have been rare with these therapies. A small number of cases of
herpes zoster have been reported in patients receiving mepolizumab. Patients with known parasitic infections were
excluded from clinical trials of these therapies; at-risk patients should be screened for parasitic infections and, if found,
treated before commencing therapy aimed at reducing eosinophils. Safety extension studies with mepolizumab390 and
with benralizumab391 have found no adverse consequences of long-term eosinophil depletion, nor evidence of increased
risk of opportunistic infections.
Anti-IL4 receptor α
Role in therapy
Dupilumab binds to interleukin-4 (IL-4) receptor alpha, blocking both IL-4 and IL-13 signaling. It is a treatment option for
patients aged ≥12 years with severe eosinophilic asthma whose asthma is uncontrolled on treatment with moderate-high
dose ICS and LABA, and for patients requiring maintenance OCS therapy for severe asthma. It is also indicated for
treatment of moderate-severe atopic dermatitis.392
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
41
Dupilumab is currently approved for ages ≥12 years, as 200mg or 300mg administered by SC injection every 2 weeks
for severe eosinophilic/Type 2 asthma, and 300mg by SC injection every 2 weeks for OCS-dependent severe asthma or
if there is concomitant moderate/severe atopic dermatitis. Self-administration may be an option.
Like other biologic agents for severe asthma, this medication is expensive, so it should only be considered when
common causes of uncontrolled asthma, including incorrect inhaler technique and poor adherence, have been checked
and addressed, and the contribution of comorbidities and modifiable risk factors to respiratory symptoms and
exacerbations has been identified and minimized. This report does not state specific criteria for eligibility for biologic
therapies, as these vary between countries and jurisdictions. For more details, see GINA Pocket Guide on Difficult-toTreat and Severe Asthma in Adults and Adolescents.197
Asthma outcomes
R
D
IS
T
R
IB
U
TE
Randomized controlled trials in patients with uncontrolled severe asthma with at least one exacerbation in the last year
was associated with~50% reduction in severe exacerbations, and significantly improved quality of life, symptom control
and lung function.393 In patients with OCS-dependent severe asthma, without minimum requirements of blood eosinophil
count or FeNO, treatment with anti-IL4R reduced median OCS dose by 50% versus placebo.394 In a meta-analysis of
four randomized controlled trials representing 2,992 patients, pooled analyses demonstrated a significant reduction in
the annualized rate of severe exacerbations in the dupilumab group compared to placebo (RR 0.44, 95% CI 0.35-0.06,
p<0.01). Dupilumab also improved FEV1 by a mean of 0.14L (95% CI 0.12-0.17L, p<0.01).
C
O
PY
O
Potential predictors of a good asthma response to anti-IL4R include higher blood eosinophils, which are strongly
predictive,393 and higher FeNO.393
T
Other outcomes
D
O
N
O
Nasal polyposis is not currently a specific indication for anti-IL4R therapy, but a randomized placebo-controlled trial
showed improved symptoms and reduced nasal polyps on endoscopy at 16 weeks.395
IA
L-
Adverse effects
TE
D
M
AT
ER
Adverse effects include injection-site reactions which are common but minor. In a meta-analysis of four randomized
controlled trials, use of dupilumab had a two-fold higher incidence of injection site reactions compared with placebo, but
was otherwise well-tolerated and there was no significant increase in adverse events or serious adverse events.396
Transient blood eosinophilia occurs in 4-13% of patients.
R
IG
PY
Role in therapy
H
Systemic corticosteroids
C
O
Long-term treatment with oral corticosteroids (OCS) (that is, for periods longer than two weeks) may be required for
severely uncontrolled asthma, but its use is limited by the risk of significant adverse effects. The therapeutic index
(effect/side effect) of long-term ICS is always more favorable than long-term systemic corticosteroids in asthma.397,398 If
OCS are to be administered on a long-term basis, attention must be paid to measures that minimize the systemic side
effects. Oral preparations are preferred over parenteral (intramuscular or intravenous) for long-term therapy because of
their lower mineralocorticoid effect, relatively short half-life, and lesser effects on striated muscle, as well as the greater
flexibility of dosing that permits titration to the lowest acceptable dose that maintains control.
Short-term use of systemic corticosteroids is important in the treatment of severe acute exacerbations because they
prevent progression of the exacerbation, reduce the need for referral to emergency departments and hospitalization,
prevent early relapse after emergency treatment, and reduce morbidity. The main clinical effects of systemic
corticosteroids in acute asthma are only evident after 4 to 6 hours. Oral therapy is preferred and is as effective as
intravenous hydrocortisone.399 A typical short course of OCS for an exacerbation is 40-50 mg prednisolone given daily
for 5 to 10 days399 depending on the severity of the exacerbation. When symptoms have subsided and lung function has
improved, the OCS can be stopped abruptly400 400,401 (or tapered, if taken for >2 weeks), provided that treatment with ICS
42
GINA Appendix Chapter 5. Pharmacology. Part A. Adults and adolescents
continues. Intramuscular injection of corticosteroids has no advantage over a short course of OCS in preventing
relapse.402 In a randomized controlled trial, a single dose of dexamethasone was inferior to prednisone for 5 days in
adult asthma patients presenting at ED with a moderate asthma exacerbation.403
Adverse effects
U
TE
The systemic side effects of long-term oral or parenteral corticosteroid treatment include osteoporosis, arterial
hypertension, diabetes, hypothalamic-pituitary-adrenal axis suppression, obesity, cataracts, glaucoma, skin thinning
leading to cutaneous striae and easy bruising, and muscle weakness. Patients with asthma who are on long-term
systemic corticosteroids in any form should receive an assessment for osteoporosis risk and based on this assessment
receive preventive treatment for osteoporosis, as recommended in 2010 guidelines from the American College of
Rheumatology.404 Factors increasing the risk of corticosteroid-induced osteoporosis include low body mass index (BMI),
current smoking, parental history of hip fracture, >3 standard alcoholic drinks/day, and higher daily or cumulative
corticosteroid treatment.404 Withdrawal of oral corticosteroids can also (rarely) elicit adrenal failure or unmask underlying
disease, such as Churg-Strauss Syndrome.405 Caution and close medical supervision are recommended when
considering the use of systemic corticosteroids.
R
D
IS
T
R
IB
Adverse effects of short-term high dose systemic therapy (corticosteroid ‘bursts’) are uncommon but include reversible
abnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, rounding of the face (‘moon
facies’), mood alteration, insomnia, hypertension, peptic ulcer, and aseptic necrosis of the femoral head.
PY
O
Macrolides
C
O
Role in therapy
D
O
N
O
T
The role of the long-term use of macrolides in asthma remains under study. A meta-analysis of randomized controlled
trials of macrolides or placebo for more than three weeks in asthma found no significant difference in FEV1 or decrease
in exacerbations; evidence was limited by incomplete reporting and heterogeneous inclusion criteria and outcomes.406
O
C
Adverse effects
PY
R
IG
H
TE
D
M
AT
ER
IA
L-
Two longer-term studies have been conducted. In a study in adult patients with uncontrolled asthma despite high dose
ICS and a history of ≥2 exacerbations requiring OCS or respiratory infections requiring antibiotics in the previous year,
low-dose azithromycin 250mg three times per week improved quality of life; in the subset with non-eosinophilic severe
asthma, azithromycin reduced severe exacerbations.407 In another study of adult patients with uncontrolled persistent
asthma on medium-to-high dose ICS plus a LABA, add-on maintenance treatment with azithromycin 500 mg three times
per week reduced asthma exacerbations and improved asthma-related quality of life.408 Treatment for at least 6 months
is suggested, as a clear benefit was not seen by 3 months. There is no clear evidence about how long treatment should
be continued.
Gastro-intestinal symptoms (e.g. diarrhoea) were more common with the higher dose of azithromycin.408 Since
macrolides such as azithromycin can elicit ototoxicity and cardiac arrhythmia, asthma patients with hearing
impairment408 or abnormal prolongation of the corrected QT interval407,408 were excluded from the studies. Before
considering add-on therapy with azithromycin in adult patients with uncontrolled (severe) asthma, sputum should be
checked for atypical mycobacteria, and the risk of increasing antimicrobial resistance at the patient and the population
level should be taken into account.
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
43
RELIEVER MEDICATIONS
Short-acting inhaled beta2-agonists (SABA)
Role in therapy
Inhaled SABAs are used for relief of bronchospasm during acute exacerbations of asthma and for the pretreatment of
exercise-induced bronchoconstriction. They include salbutamol, terbutaline, levalbuterol HFA, reproterol, and pirbuterol.
Formoterol, a LABA, is approved for symptom relief because of its rapid onset of action, but it should not be used
without concomitant ICS therapy.409
U
TE
SABAs should be used only on an as-needed basis at the lowest dose and frequency required. Increased use,
especially daily use, is a warning of deterioration of asthma control and indicates the need to reassess treatment.
Similarly, failure to achieve a quick and sustained response to SABA treatment during an exacerbation mandates
medical attention, and may indicate the need for short-term treatment with OCS. A population-based survey reported
that one-quarter of the SABA-only population had needed urgent asthma healthcare in the previous year.410
C
O
PY
O
R
D
IS
T
R
IB
From 2019, GINA no longer recommends SABA-only treatment of asthma in adults or adolescents. Because adherence
with ICS is often extremely poor, particularly in patients with infrequent symptoms, and because a feasible alternative is
now available, SABAs are no longer the preferred reliever of choice in mild asthma. Although SABAs are highly effective
for the quick relief of asthma symptoms411 (Evidence A), patients whose asthma is treated with SABA alone are at risk of
asthma-related death265 (Evidence A) and urgent asthma-related healthcare412 (Evidence A), even if they have good
symptom control.410 One long-term study of regular SABA in patients with newly-diagnosed asthma showed worse
outcomes and lower lung function than in patients who were treated with daily low dose ICS from the start.413
N
O
T
Adverse effects
AT
ER
IA
L-
D
O
Tremor and tachycardia are commonly reported with initial use of SABA, but tolerance to these effects usually develops
rapidly. Dispensing of ≥3 SABA canisters per year (average ≥1.5 puffs per day) is associated with increased risk of ED
visit or hospitalization, independent of asthma severity.414 Heavy use of SABAs (e.g. averaging more than one canister
per month) is associated with increased risk of asthma-related death.415
M
Low dose ICS-formoterol
TE
D
Role in reliever therapy
C
O
PY
R
IG
H
Low dose ICS-formoterol, taken only as needed for symptom relief, is a preferred treatment option for adults and
adolescents with mild asthma. This recommendation is supported by evidence from a large double-blind study showing
a 64% reduction in severe exacerbations compared with SABA-only treatment,306 and two large studies in mild asthma
showing non-inferiority for severe exacerbations compared with regular ICS plus as-needed SABA.306,307 The evidence
to date is with low dose budesonide-formoterol, but low dose beclometasone-formoterol should also be suitable. These
medications are well-established for as-needed use as part of maintenance and reliever therapy in GINA Steps 3-5,309
and no new safety signals were seen in the large studies with as-needed budesonide-formoterol in mild asthma.262,307
In patients with mild asthma, low dose budesonide-formoterol taken as-needed for symptom relief and before exercise
reduced exercise-induced bronchoconstriction to a similar extent over 6 weeks as regular daily low dose ICS plus SABA
for symptom relief and before exercise.334
Low dose ICS-formoterol is also the preferred reliever for patients prescribed maintenance and reliever therapy, in which
a low dose of budesonide-formoterol or beclometasone-formoterol is taken as both regular daily maintenance treatment
and as the patient’s reliever therapy. See section on Controller medications above for details. ICS-formoterol should not
be used as the reliever medication for patients taking combination ICS-LABA medications with a different (nonformoterol) LABA.
44
GINA Appendix Chapter 5. Pharmacology. Part A. Adults and adolescents
Adverse effects
In the large studies of as-needed budesonide-formoterol, no notable differences in adverse events were seen compared
with those with daily low dose ICS plus as-needed SABA.
Short-acting anticholinergics
Role in therapy
Short-acting anticholinergic bronchodilators used in asthma include ipratropium bromide and oxitropium bromide.
Inhaled ipratropium bromide is a less effective reliever medication in asthma than SABAs. A meta-analysis of trials of
inhaled ipratropium bromide use added to SABA in acute asthma showed that the anticholinergic produced a statistically
significant, albeit modest, improvement in pulmonary function, and significantly reduced the risk of hospital
admission.416,417
R
IB
U
TE
The benefits of ipratropium bromide in the long-term management of asthma have not been established, although it is
recognized as an alternative bronchodilator for patients who experience such adverse effects as tachycardia,
arrhythmia, and tremor from rapid-acting beta2-agonists.
IS
T
Adverse effects
O
R
D
Inhalation of ipratropium or oxitropium can cause dryness of the mouth and a bitter taste.
C
O
PY
OTHER MEDICATIONS
T
Theophylline
N
O
Role in therapy
M
AT
ER
IA
L-
D
O
Long-term therapy: Theophylline is a relatively weak bronchodilator and when given in a low dose, has modest antiinflammatory properties.418 It is available in sustained-release formulations that are suitable for once-or twice-daily
administration. Theophylline is an add-on option for adult patients whose asthma is not well controlled with ICS or ICSLABA.419-421 In such patients, the withdrawal of sustained-release theophylline has been associated with deterioration of
asthma control.422 However, for patients taking ICS, theophylline is less effective as add-on therapy than LABA.423
PY
Adverse effects
R
IG
H
TE
D
Short term therapy: In patients with acute asthma treated with inhaled SABA, the addition of intravenous aminophylline
compared with placebo did not result in significant additional bronchodilation. Moreover, for every hundred patients
treated with aminophylline there were an additional 20 patients with vomiting and 15 with arrhythmias.424
C
O
Side effects of theophylline, particularly at higher doses (10 mg/kg body weight/day or more), are significant and reduce
its usefulness. Side effects can be reduced by careful dose selection and monitoring, and generally decrease or
disappear with continued use. Adverse effects include gastrointestinal symptoms, diarrhea, cardiac arrhythmias,
seizures, and even death. Nausea and vomiting are the most common early events. Monitoring of blood levels is
advised when a high dose is started, if the patient develops an adverse effect on the usual dose, if expected therapeutic
aims are not achieved, and when conditions known to alter theophylline metabolism exist. For example, febrile illness,
pregnancy, and anti-tuberculosis medications425 reduce blood levels of theophylline, while liver disease, congestive
heart failure, and certain drugs including cimetidine, some quinolones, and some macrolides increase the risk of toxicity.
Lower doses of theophylline, that have been demonstrated to provide the full anti-inflammatory benefit of this drug,419
are associated with fewer side effects, and plasma theophylline levels in patients on low dose therapy need not be
measured unless overdose is suspected.
During short-term treatment, theophylline has the potential for significant adverse effects, although these can generally
be avoided by appropriate dosing and monitoring. Short-acting theophylline should not be administered to patients
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
45
already on long-term treatment with sustained-release theophylline unless the serum concentration of theophylline is
known to be low and/or can be monitored.
Oral beta-agonists
Role in therapy
Short-acting oral beta-agonists may be considered in the few patients who are unable to use inhaled medication.
However, their use is associated with a higher prevalence of adverse effects.
Long acting oral beta-agonists include slow release formulations of salbutamol, terbutaline, and bambuterol, a pro-drug
that is converted to terbutaline. They are used only on rare occasions when additional bronchodilation is needed.
Adverse effects
IS
T
R
IB
U
TE
The side effect profile of oral long-acting beta-agonists is higher than that of inhaled beta2-agonists, and includes
cardiovascular stimulation (tachycardia), anxiety, and skeletal muscle tremor. Adverse cardiovascular reactions may
also occur with the combination of oral beta-agonists and theophylline. Regular use of long-acting oral beta-agonists as
monotherapy is likely to be harmful and these medications must always be given in combination with ICS.
D
Oral anti-histamines
C
O
PY
O
R
Oral anti-allergy compounds have been introduced in some countries for the treatment of mild to moderate allergic
asthma. A meta-analysis of 19 studies on the effects of anti-histamines in adult asthma does not support the use of
these medications in asthma treatment.426 Sedation is a potential side effect of some of these medications. 426
N
O
T
Immunosuppressants
PY
Vitamin D
R
IG
H
TE
D
M
AT
ER
IA
L-
D
O
Several steroid-sparing drugs have been proposed for patients with severe asthma. The data to support their use is
weak and they should be used only in selected patients under expert supervision, as their potential steroid-sparing
effects may not outweigh the risk of serious side effects. Two meta-analyses of the steroid-sparing effect of low dose
methotrexate showed a small overall benefit, but a relatively high frequency of adverse effects.427,428 This small potential
to reduce the impact of corticosteroid side effects is probably insufficient to offset the adverse effects of methotrexate
(gastrointestinal symptoms, and on rare occasions hepatic and diffuse pulmonary parenchymal disease, and
hematological and teratogenic effects).429 Cyclosporin430 and gold431,432 have also been shown to be effective in some
patients. The use of intravenous immunoglobulin is not recommended for treatment of asthma.433-435
C
O
Vitamin D supplementation may be effective in reducing asthma exacerbations requiring systemic corticosteroids in
patients with low baseline serum levels of Vitamin D (high quality evidence), based on a meta-analysis of 7 RCTs in
children and adults with asthma. No effect on time to first exacerbation or exacerbation rates was seen. In view of the
low cost of this intervention and the economic burden associated with asthma exacerbations, vitamin D supplementation
in patients with documented vitamin D deficiency may represent a potentially cost-effective strategy.436
In a placebo-controlled trial in 408 adults with mild-moderate asthma who underwent ICS dose reduction, add-on high
dose cholecalciferol (100,000 IU load plus 4000 IU/day) for 28 weeks vs placebo did not reduce the risk of asthma
exacerbations437 or severity or frequency of colds.438
46
GINA Appendix Chapter 5. Pharmacology. Part A. Adults and adolescents
COMPLEMENTARY AND ALTERNATIVE MEDICINES AND THERAPIES
Role in therapy
The roles of complementary and alternative medicine in adult asthma treatment are limited because these approaches
have been insufficiently researched and their effectiveness is largely unproven, or has not been validated by
conventional standards.439 Although the psychotherapeutic role of the therapist forms part of the placebo effect of all
treatments, this aspect is viewed as an integral part of the so-called holistic approach used by practitioners of
complementary and alternative methods, and mitigates against performance of the large, multicenter, placebo-controlled
randomized studies required to confirm efficacy. However, without these the relative efficacy of these alternative
measures will remain unknown.
TE
Complementary and alternative therapies include acupuncture, homeopathy, herbal medicine, ayurvedic medicine,
ionizers, osteopathy and chiropractic manipulation, and speleotherapy among others. Apart from those mentioned
below, there have been no satisfactory studies from which conclusions about their efficacy can be drawn.
C
O
PY
O
R
D
IS
T
R
IB
U
Dietary supplements, including selenium therapy440 are not of proven benefit and the use of a low sodium diet as an
adjunctive therapy to normal treatment has no additional therapeutic benefit in adults with asthma. In addition, a low
sodium diet has no effect on bronchial reactivity to methacholine.441 Evidence from the most rigorous studies available to
date indicates that spinal manipulation is not an effective treatment for asthma.442 Systematic reviews indicate that
homeopathic medicines have no effects beyond placebo.443 A Cochrane review of yoga interventions for asthma (with or
without breathing, posture or meditation) compared to usual care (or sham intervention)444 found moderate quality
evidence of benefit for quality of life; there was no benefit for lung function or medication use. Few studies were matched
for contact with health professionals, and few data were available about adverse effects.444
C
O
PY
R
IG
H
TE
D
M
AT
ER
IA
L-
D
O
N
O
T
A systematic review of studies of breathing and/or relaxation exercises for asthma and/or dysfunctional breathing,
including the Buteyko method and the Papworth method, reported significant but small improvements in symptoms,
quality of life and/or psychological measures, but not in physiological outcomes or risk of exacerbations.445 A
subsequent large pragmatic study of breathing training in patients with impaired asthma-related quality of life showed
significant but small improvements in quality of life, but no difference in asthma symptom control or risk of
exacerbations. Results with three face-to-face physiotherapy sessions and DVD-based training were similar.446
Breathing exercises used in some of these studies are available for free download from www.breathestudy.co.uk 446 and
www.woolcock.org.au/moreinfo.447 In order for studies of non-pharmacological strategies such as breathing exercises to
be considered high quality, control groups should be appropriately matched for level of contact with health professionals
and for asthma education. A study of two physiologically contrasting breathing techniques, in which contact with health
professionals and instructions about rescue inhaler use were matched, showed similar improvements in reliever and ICS
use in both groups.447 This suggests that perceived improvement with breathing exercises may be largely due to factors
such as relaxation, voluntary reduction in use of SABA medication, or engagement of the patient in their own care.
Breathing exercises may thus provide a useful supplement to conventional asthma management strategies, including in
anxious patients or those habitually over-using rescue medication. The cost of some programs is a potential limitation.
Adverse effects
With acupuncture, adverse effects including hepatitis B, pneumothorax, and burns have been described. Side effects of
other alternative and complementary medicines are largely unknown. However, some popular herbal medicines could
potentially be dangerous, as exemplified by the occurrence of hepatic veno-occlusive disease associated with the
consumption of the commercially available herb, comfrey. Comfrey products are sold as herbal teas and herbal root
powders, and their toxicity is due to the presence of pyrrolizidine alkaloids.
GINA Appendix Chapter 5. Pharmacology Part A. Adults and adolescents
47
PART B. ASTHMA PHARMACOTHERAPY – CHILDREN 6–11 YEARS
ROUTE OF ADMINISTRATION
Inhaled therapy is the cornerstone of asthma treatment for children of all ages. Almost all children can be taught to
effectively use inhaled therapy. Different age groups require different inhalers for effective therapy, so the choice of
inhaler must be individualized. Information about the lung dose for a particular drug formulation is seldom available for
children, and marked differences exist between the various inhalers. This should be considered whenever one inhaler
device is substituted with another. In addition, the choice of inhaler device should include consideration of the efficacy of
drug delivery, costs, safety, ease of use, convenience, and documentation of its use in the patient’s age group.258,448
D
IS
T
R
IB
U
TE
Many children with asthma do not use their inhalers correctly and consequently gain little or no therapeutic benefit from
prescribed treatment.448 Therefore, for each age group, a major focus of inhalation therapy should be on which inhalers
are the easiest to use correctly, and how much training is required to achieve correct technique. More than 50 different
inhaler/drug combinations are now available for the treatment of asthma. Although such a variety increases the
likelihood of finding an appropriate inhaler for each individual patient, it also increases the complexity of inhaler choice,
and it may also reduce the health care provider’s experience with each device. Therefore, it may be better for the
individual health care provider to focus on a limited number of inhalers to gain better experience with them.
O
T
C
O
PY
O
R
Both initial training and repeated follow-ups are crucial for correct inhaler use in children.449 Prescription of inhaled
therapy to a child should always be accompanied by thorough training in correct inhaler use, and repeatedly checking
that the child can demonstrate correct technique. The number of cycles of correction and demonstration of technique
depend on age and the psychomotor skills of the child. Inhaler technique continues to improve when skills training is
repeated at subsequent visits.450
AT
ER
IA
L-
D
O
N
Options for inhalers include pressurized metered dose inhaler (pMDI) with or without a spacer device, and dry powder
inhaler (DPI), These differ with respect to construction, aerosol cloud generation, optimal inhalation technique and ease
of use. For children, prescription of pMDI alone (without spacer) is not generally recommended as they are more difficult
to use correctly than pMDI with spacer, DPI or breath-actuated pMDI. DPIs and breath-actuated pMDIs are often
preferred for use outside the home, as they are more convenient to carry than pMDI and spacer.
C
O
PY
R
IG
H
TE
D
M
Spacers retain large drug particles that would normally be deposited in the oropharynx; this reduces oral and
gastrointestinal absorption and thus systemic availability of the inhaled drug. This is important for ICS that have low firstpass metabolism (beclometasone dipropionate, flunisolide, triamcinolone). Use of a spacer also reduces oropharyngeal
side effects. During asthma exacerbations, a spacer should always be used with a pMDI, as in this situation a child may
be unable to correctly coordinate inhalation with pMDI actuation. Nebulizers have rather imprecise dosing, are
expensive, are time consuming to use and care for, and require maintenance. They are mainly reserved for children who
cannot use other inhaler devices. In life-threatening asthma exacerbations a nebulizer is often used, although in mild or
moderate exacerbations, pMDI with a spacer is equally effective.451
Common inhaler devices for use by children aged over 5 years, together with features of optimal inhalation technique,
and some common problems with their use are summarized in Box A5-2.
48
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
Box A5-2. Inhaler devices, optimal technique, and common problems for children
Device
pMDI with
valved spacer
Age group/context
Optimal technique
All ages
Common problems
Slow deep inhalation (30 L/min.)
followed by 5 second breath-hold
Static electricity reduces output*
(output is reduced after cleaning
unless rinsed with detergent and
air-dried)
All ages with acute severe Slow tidal breathing (5–10 cycles)
starting immediately after actuation.
wheeze
Multiple actuations into spacer
ICS with low first pass
metabolism (see text)
> 8 years
Exhalation away from device, then
Coordination of actuation and
inhaler actuation early during a slow
inhalation
(30 L/min) deep inhalation, followed by
5 second breath-hold
Breath-actuated
> 7 years
pMDI
R
D
IS
T
Slow inhalation is difficult
Exhalation away from device followed
by a deep, forceful inhalation (minimal
effective flow varies between devices)
PY
O
> 5 years
Dose lost if child exhales through
the inhaler
C
O
Dry powder
inhalers
Exhalation away from device followed
by a slow (30 L/min) deep inhalation
followed by 5 second breath-hold
R
IB
U
TE
pMDI
N
O
T
* Device dependent
D
O
CONTROLLER MEDICATIONS
ER
IA
L-
Controller medications for children include inhaled corticosteroids (ICS), combination ICS/long-acting beta2-agonists
(ICS-LABA), leukotriene receptor antagonists (LTRA) and chromones.
TE
D
Role in therapy – regular daily treatment
M
AT
Inhaled corticosteroids
C
O
PY
R
IG
H
ICS are the most effective controller therapy, and are therefore the recommended maintenance treatment for asthma,
including for children.452 Box A5-3 lists low, medium and high doses of different ICS for children 6–11 years. Concerns
around SABA-only treatment are relevant to children, as in adults, and should be considered when initiating Step 1
treatment.414
Dose-response studies and dose titration studies in children453,454 demonstrate marked and rapid clinical improvements
in symptoms and lung function at low doses of ICS,272,455,456 and mild disease is well controlled by low doses in the
majority of patients.264 Some children require higher doses to achieve optimal asthma control and effective protection
against exercise-induced asthma, but incorrect inhaler technique and poor adherence may contribute. Only a minority of
patients require treatment with high doses of ICS.272
In children, as in adults, maintenance treatment with ICS controls asthma symptoms, reduces the frequency of acute
exacerbations, the need for additional asthma medication and the number of hospital admissions, improves quality of
life, lung function, and bronchial hyperresponsiveness, and reduces exercise-induced bronchoconstriction.266 Symptom
control and improvements in lung function occur rapidly (after 1–2 weeks), although longer treatment (over months) and
sometimes higher doses may be required to achieve maximum improvements in airway hyperresponsiveness.266 When
corticosteroid treatment is discontinued, asthma control deteriorates within weeks to months.268
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
49
Box A5-3.
Low, medium and high daily doses of ICS for children 6–11 years
This is not a table of equivalence, but instead, suggested total daily doses for the ‘low’, ‘medium’ and ‘high’ dose ICS
treatment options for children 6-11 years, based on available studies and product information. Data on comparative
potency are not readily available and therefore this table does NOT imply potency equivalence. Doses may be countryspecific depending on local availability, regulatory labelling and clinical guidelines.
50-100
>400
>100-200
>200
U
Beclometasone dipropionate (pMDI, extrafine particle*, HFA)
>200–400
R
IB
100–200
IS
T
Beclometasone dipropionate (pMDI, standard particle, HFA)
TE
Low dose ICS provides most of the clinical benefit of ICS for most patients with asthma. However, ICS responsiveness
varies between patients, so some patients may need medium dose ICS if their asthma is uncontrolled despite good
adherence and correct technique with low dose ICS (with or without LABA). High dose ICS (in combination with LABA
or separately) is needed by very few patients, and its long-term use is associated with an increased risk of local and
systemic side-effects, which must be balanced against the potential benefits.
Total daily ICS dose (mcg) – see notes above
Inhaled corticosteroid
Low
Medium
High
100–200
>200–400
>400
Budesonide (nebules)
250–500
>500–1000
>1000
80
>80-160
>160
O
R
D
Budesonide (DPI)
PY
Ciclesonide (pMDI, extrafine particle*, HFA)
C
O
Fluticasone furoate (DPI)
O
T
Fluticasone propionate (DPI)
D
O
N
Fluticasone propionate (pMDI, standard particle, HFA)
n.a.
50-100
>100-200
>200
50-100
>100-200
>200
100
200
L-
Mometasone furoate (pMDI, standard particle, HFA)
50
AT
ER
IA
DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant; ICS: inhaled corticosteroid; n.a. not applicable; pMDI: pressurized metered dose inhaler
(non-chlorofluorocarbon formulations); ICS by pMDI should preferably be used with a spacer. *See product information.
R
IG
H
TE
D
M
Most of the clinical benefit from ICS is seen at low doses, and clear evidence of dose-response relationships is seldom
available within the dose ranges evaluated for regulatory purposes. ‘High’ doses are arbitrary, but for most ICS are
those that, with prolonged use, are associated with increased risk of systemic side-effects.
O
PY
For new preparations, including generic ICS, the manufacturer’s information should be reviewed carefully; products
containing the same molecule may not be clinically equivalent. For more detailed discussion see Raissy et al. 271
C
Role in therapy - as-needed treatment
Meta-analyses of asthma treatment in school-age children have sometimes compared regular ICS with either
intermittent ICS (episodic) or as-needed (prn) ICS, the latter taken whenever SABA was taken.457458 However, these two
regimens are likely to differ in their clinical effectiveness. Daily treatment was reported to be superior to intermittent or
prn treatment in several indicators of lung function, airway inflammation, asthma control and reliever use. However,
taking ICS whenever SABA was taken substantially reduced the risk of asthma exacerbations compared with SABA-only
treatment.459 Both treatments appeared safe, but growth was slower (0.4 cm/year) in the regular treatment group. None
of the studies recorded lifestyle factors such as daily physical activity or changes in fitness, which have been found to be
reduced in children when their asthma is not optimally controlled.460 The authors concluded that there was low quality
evidence that intermittent and daily ICS strategies were similarly effective in the use of rescue oral corticosteroids and
the rate of severe adverse health events, but that equivalence between the two options could not be assumed.
A further study in which patients were instructed to take ICS whenever SABA is taken was conducted in AfricanAmerican children aged 6-17 years, using separate ICS and SABA inhalers. This study found similar outcomes as
50
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
physician-adjusted treatment but with lower average ICS dose461 Interviews with parents indicated that those whose
children were randomized to as-needed ICS+SABA felt more in control of their child’s asthma than those whose children
were randomized to physician-based adjustment.461
Adverse effects
R
IB
U
TE
Growth. When assessing the effects of ICS on growth in children with asthma, it is important to remember that
uncontrolled or severe asthma adversely affects growth and final adult height.462 Potential confounding factors also
affect interpretation. For example, many children with asthma, especially severe asthma, experience a reduction in
growth rate toward the end of the first decade of life. This continues into the mid-teens and is associated with a delay in
the onset of puberty. This deceleration of growth velocity resembles growth retardation, but is also associated with a
delay in skeletal maturation, so that the child’s bone age corresponds to his or her height. Ultimately, adult height is not
decreased, although it is reached at a later than normal age.462,463 One study suggested that 400 mcg inhaled
budesonide or equivalent per day to control asthma has less impact on growth than a low socioeconomic status.463 A
summary of the findings of studies on ICS and growth is provided in Box A5-4.462,464,465
IS
T
Box A5-4. Corticosteroids and growth in children
R
IG
H
TE
D
M
AT
ER
IA
L-
D
O
N
O
T
C
O
PY
O
R
D
• Uncontrolled or severe asthma adversely affects growth and final adult height.462
• Daily use of 100–200 mcg ICS is generally considered to be without any clinically important adverse
effects on growth.
• Growth retardation in both short- and medium-term studies is dose dependent. Growth retardation may be
seen with moderate or high doses of all ICS.
• Important differences seem to exist between the growth-retarding effects of different ICS and different
devices.
• Corticosteroid-induced changes in growth rate during the first year of treatment are not progressive or
cumulative.
• In several studies, children with asthma treated with ICS for several years have been found to attain
normal adult height.264,462,463 However, one randomized, controlled trial of 5 years treatment with inhaled
budesonide 400 mcg/day found that the initial 1.2 cm reduction in height was still detectable in adulthood
(<1% of adult height), particularly in children who started treatment before 10 years of age.464 Evidence
favors the use of low dose ICS where possible.466
C
O
PY
Bones. Several cross-sectional and longitudinal epidemiologic studies have assessed whether long-term ICS treatment
is associated with osteoporosis and fractures.467-473. The conclusions are summarized in Box A5-5.
Box A5-5. Corticosteroids and bones in children
• No studies have reported an increased risk of fractures in children taking ICS.
• Use of oral or systemic corticosteroids increases the risk of fracture. The risk increases with the number of
treatments, with a 32% increase after four courses (lifetime). ICS reduce the need for systemic
corticosteroid courses.
• Controlled longitudinal studies of 2–5 years’ duration, and several cross-sectional studies, found no
adverse effects of ICS on bone mineral density.
• ICS use has the potential for reducing bone mineral accretion in male children progressing through
puberty, but this risk is likely to be outweighed by the ability to reduce the amount of oral corticosteroids
used in these children.474
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
51
Hypothalamic-pituitary-adrenal (HPA) axis: Although differences exist between different ICS and inhaler devices,
treatment with ICS doses of less than 200 mcg budesonide or equivalent daily is not normally associated with any
significant suppression of the HPA axis in children.266 At higher doses, small changes in HPA axis function can be
detected with sensitive methods.471 The clinical relevance of these findings is not known, since there have been no
reports of adrenal crisis in clinical trials of ICS in children. However, adrenal crisis has been reported in children treated
in clinical practice with excessively high ICS doses.475
Cataracts: ICS have not been associated with an increased occurrence of cataract development in children.297,476
Central nervous system effects: Although isolated case reports have suggested that hyperactive behavior,
aggressiveness, insomnia, uninhibited behavior, and impaired concentration may be seen with ICS treatment, no
increase in such effects has been found in two long-term controlled trials of inhaled budesonide involving more than
10,000 treatment years.264,266
IS
T
R
IB
U
TE
Oral candidiasis, hoarseness, and bruising: Clinical thrush is seldom a problem in children treated with ICS or oral
corticosteroids. This side effect seems to be related to concomitant use of antibiotics, high daily doses, dose frequency,
and inhaler device. Spacers reduce the incidence of oral candidiasis.477 Mouth rinsing is beneficial.478 The occurrence of
hoarseness or other noticeable voice changes during budesonide treatment is similar to placebo.297 Treatment with an
average daily dose of 500 mcg budesonide for 3–6 years is not associated with an increased tendency to bruise.297
O
R
D
Dental side effects: ICS treatment is not associated with increased incidence of caries. However, the increased level of
dental erosion reported in children with asthma479 may be due to a reduction in oral pH from inhalation of beta2-
C
O
PY
agonists.480
N
O
T
Other local side effects: The long-term use of ICS in children is not associated with an increased incidence of lower
respiratory tract infections, including tuberculosis.
L-
D
O
Combination ICS-LABAs
ER
IA
Role in therapy
C
O
PY
R
IG
H
TE
D
M
AT
In children 6 years and older, LABAs are primarily used as add-on therapy for those whose asthma is insufficiently
controlled by medium doses of ICS. Combination ICS-LABA products are preferred to use of separate inhalers, to
ensure that the LABA is always accompanied by ICS. With add-on LABA, significant improvements in peak flow and
other lung function measurements have been found in most studies.481-483 However, the effects on other outcomes such
as symptoms and need for reliever medication have been less consistent, and only observed in about half of the trials
conducted. A cross-over study in children whose asthma was uncontrolled despite good adherence with low-dose ICS
(n=182) found that adding LABA was most likely to produce the best clinical response over 16 weeks for a composite
measure including lung function, compared with adding a LTRA or doubling the ICS dose.484
For exacerbations in children, by contrast with findings in adults, meta-analyses of randomized controlled trials showed
no significant difference in exacerbations requiring systemic corticosteroids, when LABA was added to current treatment
(which may or may not have included ICS),485 when LABA was added to ICS,486 or when ICS-LABA was compared with
double dose ICS.487 A large (n=6,208) study in children 4-11 years found no significant difference in serious
exacerbations requiring hospitalization, or in severe exacerbations requiring oral corticosteroids, between fluticasone
propionate and same dose combination fluticasone propionate/salmeterol.488
A single study of maintenance and reliever therapy with low dose budesonide-formoterol in children showed a large
reduction in exacerbations compared with the same dose of budesonide-formoterol with SABA reliever, or compared
with higher dose ICS.489
Not all combination ICS-LABA medications and devices are approved for use in children.
52
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
Adverse effects
There have been concerns that using LABA might increase asthma risks including mortality.490 However, a large
randomized controlled trial with fluticasone propionate/salmeterol combination inhaler in children 4-11 years showed no
inferiority to fluticasone propionate alone for serious adverse events (death, intubation and hospitalization due to
asthma).343,488 Based on this study488 and a systematic review490 there is no apparent increase in risk for serious
exacerbations in children with LABA when it is used in a combination inhaler with ICS.
Leukotriene receptor antagonists
Role in therapy
IS
T
R
IB
U
TE
LTRAs provide clinical benefit in this age group at all levels of severity,352,491-493 but the benefit is generally less than that
of low dose ICS.452 LTRAs provide partial protection against exercise-induced bronchoconstriction within hours after
administration with no loss of bronchoprotective effect over time.221,494 A systematic review of LTRAs as add-on
treatment in children whose asthma was insufficiently controlled by low doses of ICS showed no significant improvement
in outcomes, including in exacerbations.495 Add-on therapy with montelukast was less effective in controlling asthma in
children with uncontrolled persistent asthma than increasing ICS to moderate dose.496 Montelukast has not been
demonstrated to be an effective ICS-sparing alternative in children with moderate-to-severe persistent asthma.497
R
D
Adverse effects
IA
L-
D
O
N
O
T
C
O
PY
O
No safety concerns have been demonstrated from the use of LTRA in children in clinical trials. Post-marketing
surveillance reports suggested a slight increase in the rate of (rare) neuropsychiatric disorders potentially associated
with use of leukotriene receptor antagonists in children and young adults, but no evidence was found in a case-control
study.358 Patients should be counselled about the risk of neuropsychiatric events with montelukast and health
professionals consider the benefits and risks of mental health side effects before prescribing. (ref
https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-boxed-warning-about-serious-mental-health-sideeffects-asthma-and-allergy-drug)
AT
ER
Chromones: sodium cromoglycate and nedocromil sodium
M
Role in therapy
PY
R
IG
H
TE
D
Sodium cromoglycate and nedocromil sodium have a limited role in the long-term treatment of asthma in children. One
meta-analysis concluded that long-term treatment with sodium cromoglycate is not significantly better than placebo for
management of asthma in children.498 Another meta-analysis confirmed superiority of low-dose ICS over sodium
cromoglycate in persistent asthma; no difference between treatments was seen in safety.359
C
O
Nedocromil sodium has been shown to reduce exacerbations, but its effect on other asthma outcomes is not superior to
placebo.266 A single dose of sodium cromoglycate or nedocromil sodium attenuates bronchospasm induced by exercise
or cold air.499
Sodium cromoglycate and nedocromil sodium inhalers require daily washing to prevent blockage.
Adverse effects
Cough, throat irritation, and bronchoconstriction occur in a small proportion of patients treated with sodium
cromoglycate. A bad taste, headache, and nausea are the most common side effects of nedocromil.500
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
53
ADD-ON CONTROLLER MEDICATIONS
Long-acting anticholinergics (also called long-acting antimuscarinics, LAMA)
Role in therapy
A meta-analysis of over 900 patients 6-11 years showed the addition of tiotropium to medium or high dose ICS with or
without a second controller was associated with significant improvements in FEV1 and Asthma Control Questionnaire
responders, and reduced the number of patients with one or more exacerbations, but with no differences in reliever use.
The approved dose for children varies between regulatory authorities.501
Anti-IgE
Role in therapy
C
O
PY
O
R
D
IS
T
R
IB
U
TE
Anti-IgE (omalizumab) has proven effect in children aged ≥6 years with moderate-to-severe and severe persistent
allergic (IgE-mediated) asthma. The efficacy of anti-IgE in children and adolescents is supported by the findings of
effectiveness studies.502 A 28-week, randomized, placebo-controlled study503 included 334 children aged 6–12 years
with moderate to severe allergic asthma, whose asthma was well controlled on ICS doses equivalent to 200–500
mcg/day of beclometasone. There were no differences in clinical effects between placebo and anti-IgE during a 16-week
stable ICS dose period. During a 12-week tapering period, urgent unscheduled physician visits were significantly
reduced by 30.3% in the anti-IgE group compared with placebo (12.9%) group,503 and there were significant
improvements in quality of life in the patients receiving anti-IgE, both during stable ICS dosing and during tapering.504
The remaining outcomes were similar in the two treatment groups.
L-
D
O
N
O
T
A one-year study evaluated the efficacy and safety of anti-IgE in 627 children aged 6–11 years with IgE-mediated
asthma inadequately controlled on ICS at doses equivalent to or higher than 200 mcg/day fluticasone propionate (mean
dose 500 mcg/day).505 Anti-IgE treatment was associated with a significantly lower exacerbation rate, and the overall
incidence of serious adverse events was significantly lower in the children receiving anti-IgE than placebo.
AT
ER
IA
A 60-week study in 419 inner-city patients aged 6-20 years found that omalizumab significantly reduced symptoms and
exacerbations, including seasonal exacerbations, compared with placebo.379
TE
D
M
A substantial number of children with difficult asthma have higher IgE levels than the upper limit of IgE recommended for
therapy (1,300 IU).506 It is unknown if these patients will still benefit from omalizumab therapy.
C
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PY
R
IG
H
The recent ERS/ATS Task Force on Severe Asthma recommended that ‘Those adults and children aged 6 and above,
with severe asthma who are considered for a trial of omalizumab, should have confirmed IgE-dependent allergic asthma
uncontrolled despite optimal pharmacological and non-pharmacological management and appropriate allergen
avoidance if their total serum IgE level is 30 to 700 IU/mL (in 3 studies the range was wider – 30–1300 IU/mL).
Treatment response should be globally assessed by the treating physician taking into consideration any improvement in
asthma control, reduction in exacerbations and unscheduled healthcare utilisation, and improvement in quality of life. If a
patient does not respond within 4 months of initiating treatment, it is unlikely that further administration of omalizumab
will be beneficial.’243
Adverse effects
Drug-related adverse events in anti-IgE treated patients are mild to moderate in severity and include injection site pain,
urticaria, rash, flushing, and pruritus.503 The long-term (beyond one year) safety and efficacy have not yet been studied
in children.
54
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
Anti-IL5
Mepolizumab is approved in Europe for children 6 years and older with severe eosinophilic asthma. However, efficacy
data in this population are limited to one very small open label uncontrolled study.507
Systemic corticosteroids
Because of the side effects of prolonged use, oral corticosteroids in children with asthma should be restricted to the
treatment of acute severe exacerbations, whether viral-induced or otherwise. Even short-courses of oral corticosteroids,
if used repeatedly, increase the risk of side-effects. In a prospective study, short courses of oral corticosteroids were
associated with reduced bone density in boys.474 In an epidemiological study, risk of fracture was increased with ≥4
courses of oral corticosteroids, although the contribution of disease severity could not be estimated.470
RELIEVER MEDICATIONS
U
TE
Short-acting beta-agonists (SABA)
R
IB
Role in therapy
O
T
C
O
PY
O
R
D
IS
T
SABAs are the most effective bronchodilators approved for this agegroup, and therefore the preferred treatment for
acute asthma in children of all ages. The inhaled route results in more rapid bronchodilation at a lower dose and with
fewer side effects than oral or intravenous administration.508 Furthermore, inhaled therapy offers significant protection
against exercise-induced bronchoconstriction and other challenges for 0.5 to 2 hours.221 This is not seen after systemic
administration.509 Oral therapy is rarely needed and is reserved mainly for the small proportion of young children who
cannot use inhaled therapy.
D
O
N
Adverse effects
AT
ER
IA
L-
Skeletal muscle tremor, headache, palpitations, and some agitation are the most common complaints associated with
high doses of beta-agonists in children. These complaints are more common after systemic administration and
disappear with continued treatment.
M
As-needed ICS-formoterol
PY
O
Role in therapy
C
Anticholinergics
R
IG
H
TE
D
There is only one study of maintenance and reliever therapy with low dose ICS-formoterol in this age-group. It showed a
large reduction in risk of severe exacerbations compared with maintenance-only treatment with ICS-formoterol plus asneeded SABA.489
Inhaled anticholinergics such as ipratropium bromide are not recommended for long-term management of asthma in
children.510 They may be tried in patients who are very sensitive to the side effects of SABAs, but their onset of action
and maximum effect are generally lower than those of SABAs.
OTHER MEDICATIONS, NOT RECOMMENDED FOR USE IN CHILDREN
Theophylline (not recommended)
Role in therapy
Due to its high toxicity, theophylline is not recommended for use in children. Theophylline has only modest effects as
monotherapy compared with placebo,511 and as add-on treatment to inhaled or oral corticosteroids in children with
severe asthma.512,513 It has a marginal protective effect against exercise-induced bronchoconstriction.514 Most clinical
evidence in children has been obtained from studies in which plasma theophylline levels were maintained within the
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
55
therapeutic range of 55–110 umol/L (5–10 mcg/ml). Theophylline elimination may vary up to tenfold between individuals,
and measurement of plasma theophylline levels is recommended in otherwise healthy children when daily doses exceed
10 mg/kg/day.
Adverse effects
The most common side effects of theophylline are anorexia, nausea, vomiting, and headache,515 mainly seen at doses
higher than 10 mg/kg/day. The risk of adverse effects is reduced if treatment is initiated with daily doses around 5
mg/kg/day and then gradually increased to 10 mg/ kg/day. More serious side effects such as epileptic seizures may
occur, and severe overdosing with theophylline can be fatal.
Long-acting oral beta-agonists (not recommended)
C
O
PY
R
IG
H
TE
D
M
AT
ER
IA
L-
D
O
N
O
T
C
O
PY
O
R
D
IS
T
R
IB
U
TE
Treatment with long-acting oral beta-agonists such as slow release formulations of salbutamol, terbutaline, and
bambuterol reduces nocturnal symptoms of asthma.516,517 However, due to their potential side effects of cardiovascular
stimulation, anxiety, and skeletal muscle tremor, their use is not encouraged. Oral long-acting beta2-agonist therapy
offers little or no protection against exercise-induced bronchoconstriction.
56
GINA Appendix Chapter 5. Pharmacology Part B. Children 6–11 years
PART C. ASTHMA PHARMACOTHERAPY – CHILDREN 5 YEARS AND YOUNGER
CONTROLLER MEDICATIONS
Inhaled corticosteroids
Role in therapy
TE
Regular ICS treatment. A meta-analysis of 29 randomized controlled trials of ≥4 weeks’ duration in children aged 1
month to 5 years, with a clinical diagnosis of wheezing or asthma for at least 6 months before study entry, found that
those who received maintenance ICS had significantly less wheezing, fewer asthma exacerbations, fewer withdrawals
caused by wheezing or asthma exacerbations, less albuterol use and more clinical and functional improvement than
those on placebo518 (Evidence A). A meta-analysis of 8 studies in children with persistent asthma showed reduced
exacerbations with daily ICS compared with placebo, and in one study, with daily ICS compared with montelukast.519
PY
O
R
D
IS
T
R
IB
U
Dose-response relationships have been less well studied in this age group. The clinical response may differ depending
on the specific device used for delivery and the child’s ability to use it correctly. For children whose asthma is not wellcontrolled with low dose ICS (Box A5-6), near-maximum benefits are achieved in the majority of patients with twice
these doses, when given as regular, long-term treatment and with correct use of a spacer device.520,521 Use of ICS for
children up to 2 years of age has not been found to induce remission of asthma; symptoms almost always return when
treatment is stopped522 (Evidence B).
C
O
Box A5-6. Low daily doses of inhaled corticosteroids for children 5 years and younger
ER
IA
L-
D
O
N
O
T
This is not a table of equivalence, but instead, suggestions for ‘low’ total daily doses for the ICS treatment
recommendations for children aged 5 years and younger, based on available studies and product information. Data on
comparative potency are not readily available, particularly for children, and this table does NOT imply potency
equivalence. The doses listed here are the lowest approved doses for which safety and effectiveness have been
adequately studied in this age group.
H
TE
D
M
AT
Low dose ICS provides most of the clinical benefit for most children with asthma. Higher doses are associated with an
increased risk of local and systemic side-effects, which must be balanced against potential benefits.
Low total daily dose (mcg)
Inhaled corticosteroid
(age-group with adequate safety and effectiveness data)
100 (ages 5 years and older)
BDP (pMDI, extrafine particle, HFA)
50 (ages 5 years and older)
O
PY
R
IG
BDP (pMDI, standard particle, HFA)
500 (ages 1 year and older)
Fluticasone propionate (pMDI, standard particle, HFA)
50 (ages 4 years and older)
C
Budesonide nebulized
Fluticasone furoate (DPI)
Not sufficiently studied in children 5 years and younger)
Mometasone furoate (pMDI, standard particle, HFA)
Ciclesonide (pMDI, extrafine particle, HFA)
100 (ages 4 years and older)
Not sufficiently studied in children 5 years and younger
BDP: beclometasone dipropionate; DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant; ICS: inhaled corticosteroid; pMDI: pressurized metered
dose inhaler (non-chlorofluorocarbon formulations); in children, pMDI should always be used with a spacer
Episodic ICS treatment versus placebo. In children with intermittent asthma or viral-induced wheeze, meta-analysis of 5
studies (422 children) found that the preemptive use of high-dose episodic ICS compared with placebo resulted in
reduced risk of exacerbation.519 Because of the potential for side-effects, this option should be considered only where
the physician is confident that the medications will be used appropriately. In children aged 2–12 years with acute
GINA Appendix Chapter 5. Pharmacology Part C. Children 5 years and younger
57
asthma, adding a single dose of nebulized ICS to an initial dose of prednisolone was no better than adding placebo in
preventing admission.523
Episodic ICS treatment versus regular ICS. The MIST study recruited pre-schoolers with recurrent wheeze, a positive
asthma predictive index (API), and wheezing episodes on an average of one third of days, with two-thirds of the children
taking ICS prior to entry. This study compared regular daily low-dose nebulized budesonide with episodic high-dose
nebulized budesonide given each night for seven days with respiratory tract illnesses.524. This study showed similar
outcomes for regular and intermittent ICS. Cumulative ICS dose was higher with regular versus episodic treatment.
TE
As-needed ICS treatment (taken when SABA is required) versus regular ICS or placebo. The ‘BEST for Children’ study
was a 3 month placebo-controlled study in 276 pre-schoolers with frequent wheeze comparing regular twice-daily
nebulized beclometasone, as-needed nebulized beclometasone/salbutamol (given for symptom relief), and as-needed
salbutamol alone.525 This study showed similar clinical outcomes for regular vs as-needed ICS, but regular ICS was
better than placebo for the primary outcome measure of symptom-free days. Cumulative ICS dose was lower with asneeded versus regular ICS.
PY
O
R
D
IS
T
R
IB
U
The choice between regular, intermittent and as-needed controller treatment in clinical practice in pre-school children is
still under discussion. A meta-analysis found strong evidence to support daily ICS for preventing exacerbations in
preschool children with recurrent wheeze, specifically in children with persistent asthma.519 For pre-school children with
frequent viral-induced wheezing and interval asthma symptoms, as-needed (prn)525 or episodic ICS526 may be
considered, but a trial of regular daily low dose ICS should be undertaken first. The effect on exacerbation risk seems
similar for regular daily low dose and episodic high dose ICS.519
C
O
Adverse effects
PY
R
IG
H
TE
D
M
AT
ER
IA
L-
D
O
N
O
T
The majority of studies evaluating the systemic effects of ICS have been undertaken in children older than 5 years.
However, the available data in children 5 years and younger suggest that, as in older children, clinically effective doses
of ICS are safe and the potential risks are well balanced by the clinical benefits.522,527,528 Generally, low doses of ICS
(Box A5-6) have not been associated with any clinically serious adverse systemic effects in clinical trials and are
considered safe520,521,527-535 (Evidence A). However, higher doses have been associated with detectable systemic effects
on growth particularly in the first year of treatment and on the hypothalamic-pituitary-adrenal (HPA) axis.520-522,527-535
These effects are similar to those reported in studies of older children that find no evidence that the initial effect on
growth is accumulated with continued long term treatment.462-464 The effects of the early reduction in growth on adult
height has not been studied in children who started ICS before the age of 5 years. In children who had been treated with
fluticasone propionate for 2 years from the age of 2 or 3 years,522 catch-up in growth was seen at 2 years after cessation
of ICS; however, in a post hoc analysis no catch-up was seen in children who at study entry were <2 years old and
weighed <15 kg.536
C
O
Local side effects, such as hoarseness and candidiasis, are rare in children 5 years and younger.271,533
Combination ICS/long-acting beta2-agonists (ICS-LABA)
A short term (8 weeks) placebo-controlled study did not show any significant difference in symptoms between
fluticasone propionate-salmeterol vs fluticasone propionate alone; no additional safety signals were noted in the group
receiving LABA.537 There are insufficient data about the efficacy and safety of ICS-LABA in children 4 years and younger
to recommend their use in this age-group.
Leukotriene receptor antagonists (LTRA)
Role in therapy
LTRA versus placebo: In a three-month placebo-controlled study of 689 children with persistent wheeze, montelukast
reduced days with symptoms and days with rescue beta2-agonist use by approximately 6 percentage points. The
proportion of children experiencing an asthma ‘attack’ was not significantly reduced, but the proportion needing a course
58
GINA Appendix Chapter 5. Pharmacology Part C. Children 5 years and younger
of prednisolone was reduced from 28% to 19%.538 In a 12-month placebo-controlled study of 549 young children with
recurrent viral-induced wheezing, regular montelukast improved some asthma outcomes compared with placebo, but did
not reduce the frequency of hospitalizations, courses of prednisone, or symptom-free days.539 These findings were
confirmed by a further study in children with intermittent wheezing.540 Montelukast has also been shown to reduce
airway hyperresponsiveness to methacholine541 or hyperventilation with cold dry air.542
Regular LTRA versus regular ICS: A recent systematic review concluded that in pre-schoolers with asthma or recurrent
wheezing, daily ICS was more effective in improving symptom control and reducing exacerbations than regular LRTA
monotherapy.543
R
IB
U
TE
Episodic LTRA treatment versus placebo. In a 12-month placebo-controlled study in children with intermittent asthma
that included 162 children aged 2–5 years, parent-initiated montelukast for 7–14 days had a modest effect on health
care utilization.544. In a placebo-controlled study of 979 children aged 3 months to 2 years, and hospitalized with RSV
bronchiolitis, montelukast had no effect on post-bronchiolitic wheeze or cough.545 A large 12-month study comparing
daily and intermittent montelukast with placebo showed no significant difference in health care utilization. There were
numerical differences in symptoms and reliever use during respiratory infections with regular and episodic montelukast
compared with placebo.540
O
R
D
IS
T
A placebo-controlled trial of the addition of montelukast to usual asthma therapy for 45 days in the fall, including 42
children aged 2–5546 found that this treatment reduced the number of days with worsening of asthma symptoms in boys
but not in girls.
O
T
C
O
PY
In summary, LTRAs improve some asthma outcomes in young children with intermittent wheezing or persistent asthma,
but to a lesser extent than daily ICS (Evidence A). However, the role of LTRAs as add-on therapy in children 5 years
and younger whose asthma is uncontrolled on ICS has not been sufficiently evaluated.
D
O
N
Adverse effects
M
AT
ER
IA
L-
No safety concerns have been demonstrated in clinical trials of LTRAs in young children. Product information for
montelukast describes (rare) adverse effects such as nightmares in this age group. Parents should be counselled about
the risk of the impact on sleep and behavior with montelukast and health professionals should consider the benefits and
risks of side effects before prescribing; the FDA has required a boxed warning about these problems.547
TE
D
Chromones (sodium cromoglycate and nedocromil sodium)
C
O
PY
R
IG
H
A Cochrane review concluded that there was no beneficial effect of inhaled sodium cromoglycate compared with
placebo in preschool children 548 (Evidence A). Two studies of nearly 1,000 children in this age group549,550 have
confirmed the superiority of ICS over chromones for almost all endpoints assessing asthma control (Evidence A).
Nedocromil sodium has not been studied in preschool children. Chromones cannot be recommended in this age group.
Oral and other systemic corticosteroids
Because of the side effects associated with prolonged use, oral corticosteroids in young children with asthma should be
restricted to the treatment of severe exacerbations, whether viral-induced or otherwise551 (Evidence D), and their use
minimized because of the potential for long-term adverse effects.
Azithromycin
Antibiotics are not currently recommended for treatment of asthma exacerbations in adults or children, but they are
commonly used in clinical practice. Two studies have examined the effect of azithromycin in selected children with a
history of severe wheezing with respiratory infections. In a large study, children 1-5 years were randomized to receive 5
days of azithromycin or placebo for respiratory infections; this study showed a significant reduction in the risk of more
severe lower respiratory episodes.552 In a smaller study in children 1-3 years, each respiratory infection lasting ≥3 days
was randomly allocated to treatment with azithromycin or placebo for 3 days, with most children also receiving ICS; this
GINA Appendix Chapter 5. Pharmacology Part C. Children 5 years and younger
59
study showed a significant reduction in symptom duration with azithromycin.553 Neither study found a difference in need
for urgent health care (which was uncommon in both studies), or an increase in time to subsequent respiratory
infections. Development of antibiotic resistance was slightly increased when examined in a small number of subjects.552
It is still unclear which children should be considered for azithromycin treatment, and there is concern about the potential
for greater antibiotic resistance in broader populations where adherence may be lower; more clinical trials are needed,
using standardized outcome measures, before any recommendations can be made.
RELIEVER MEDICATIONS
Inhaled short-acting beta2-agonists (SABA)
U
TE
Inhaled SABA are the preferred reliever treatment for asthma in children 5 years and younger (Evidence A). In most
cases, a pMDI with spacer is an effective way for delivering reliever therapy for as-needed use or in acute
exacerbations.451,554 (Evidence A). A face mask is added for children under 4 years. When delivery is not optimal
because of lack of cooperation or distress, or when the child is hypoxic, nebulizer therapy is also an option.
IS
T
R
IB
Other bronchodilators
PY
O
R
D
There is no evidence to support the use of anticholinergic agents such as inhaled ipratropium bromide in the routine
daily management of asthma in children 5 years and younger.555 (Evidence A) However, there is increasing evidence
that ipratropium is effective when added to other therapy in patients with severe exacerbations.556
C
O
Oral bronchodilator therapy is not recommended due to its slower onset of action and the higher rate of side effects.
O
T
Other therapies
D
O
N
Theophylline (not recommended)
AT
ER
IA
L-
Theophylline is not recommended for use in children. Although a few studies in children 5 years and younger suggest
clinical benefit from regular use of theophylline, the effects are small and mostly non-significant.511 The efficacy of
theophylline as initial therapy is less than that of low dose ICS, and side effects are more common.511
M
Allergen immunotherapy
C
O
PY
R
IG
H
TE
D
Immunotherapy is not recommended for the treatment or prophylaxis of asthma in children 5 years and younger
(Evidence D).
60
GINA Appendix Chapter 5. Pharmacology Part C. Children 5 years and younger
Chapter 6.
Implementing asthma management strategies in health
systems
KEY POINTS
O
R
D
IS
T
R
IB
U
TE
• In order to improve asthma care and patient outcomes, evidence-based recommendations must be not
only developed, but also adequately disseminated and implemented at a national and local level, and
integrated into current practice.
• Implementation requires an evidence-based strategy involving professional groups and stakeholders, and
should take into account local cultural and socioeconomic conditions and cost-effectiveness, so a decision
can be made to pursue or modify them.
• GINA aims to guide implementation of its recommendations, provide examples of current implementation
strategies, and offer a series of tools to help achieve this goal worldwide.
C
O
PY
INTRODUCTION
IA
L-
D
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N
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Due to the exponential increase in medical research publications, practical syntheses are needed to guide health care
providers in delivering evidence-based care. Where asthma care is consistent with evidence-based recommendations,
outcomes improve.557-559 Strategy documents such as the Global Strategy for Asthma Management and Prevention
provide a common template for health professionals to identify the main goals of treatment and the actions required to
ensure their fulfilment in their own health system, as well as to facilitate the establishment of standards of care.
TE
D
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AT
ER
Guidelines and clinical practice recommendations now generally utilize specific methodology for evaluating and adapting
evidence, ensuring development of unbiased, well-adapted recommendations.560,561 However, increasing effort should
be devoted to dissemination of recommendations and, most importantly, to their implementation at different levels so
that integration into care is promoted and facilitated.
C
O
PY
R
IG
H
The recent adoption of rigorous methodologies such as GRADE560 for the development of clinical practice
recommendations, and the ADAPTE and similar approaches for assisting the adaptation of recommendations for local
country and regional conditions, has assisted in reducing biased opinion as the basis for asthma programs worldwide.
However, use of the GRADE method is costly and often requires expertise that is not available locally, and regular
revision to remain abreast of developments (drug availability and new evidence) is not easily achieved 560,561 In addition,
there is generally very limited high quality evidence addressing the many decision nodes in comprehensive clinical
practice guidelines, particularly in developing countries.
GINA provides assistance for the processes of adaptation and implementation through provision of the Global Strategy
for Asthma Management and Prevention report,29 which contains evidence relevant to asthma diagnosis, management
and prevention that may be used in the formulation and adaptation of local guidelines; where evidence is lacking, the
GINA report provides approaches for consideration. An implementation ‘toolkit’ is also being developed, to provide a
guide to local adaptation and implementation, with materials and advice from successful examples of asthma clinical
practice guideline development and implementation in different settings.
Many barriers to, and facilitators of, implementation procedures have been described.562-565. Some of these are related
to delivery of care, while others relate to patients’ attitudes and behaviors (Box A6-1). Cultural and economic barriers
can particularly affect the application of recommendations.
GINA Appendix Chapter 6. Implementing asthma management strategies in health systems
61
Box A6-1 Examples of barriers to the implementation of evidence-based recommendations
Health care providers
Patients
• Low health literacy
• Insufficient understanding of asthma and its
management
• Lack of agreement with recommendations
• Cultural and economic barriers
• Peer influence
• Attitudes, beliefs, preferences, fears and
misconceptions
U
TE
• Insufficient knowledge of recommendations
• Lack of agreement with recommendations or
expectation that they will be effective
• Resistance to change
• External barriers (organizational, health policies,
financial constraints)
• Lack of time and resources
• Medico-legal issues
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PLANNING AN IMPLEMENTATION STRATEGY
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Implementation of asthma management strategies can be carried out at national, regional or local levels.566 Ideally, this
should be a multidisciplinary effort involving many stakeholders, and using methods of knowledge translation that are
considered cost effective.565-567 Any implementation initiative needs to consider the structure and function of the relevant
health network and its components. Moreover, goals and implementation strategies will vary from country to country and
within countries based on economics, culture and the physical and social environment.
D
O
N
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T
The essential elements required to implement a health-related strategy are summarized in Box A6-2. The goals and
processes for each of these components are summarized in the paragraphs that follow.
AT
1. Develop a multidisciplinary working group
ER
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Box A6-2. Essential elements required to implement a health-related strategy
M
2. Assess the current status of asthma care delivery, care gaps and current needs
H
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D
3. Select the material to be implemented, agree on main goals, identify key recommendations for diagnosis
and treatment, and adapt them to the local context or environment
R
IG
4. Identify barriers to, and facilitators of, implementation
PY
5. Select an implementation framework and its component strategies
C
O
6. Develop a step-by-step implementation plan:
o
Select target populations and evaluable outcomes
o
Set timelines
o
Evaluate outcomes
o
o
Identify local resources to support implementation
Distribute tasks to members
7. Continuously review progress and results to determine if the strategy requires modification
62
GINA Appendix Chapter 6. Implementing asthma management strategies in health systems
1. Develop a multidisciplinary working group
From its initiation, the working group should ideally include representation from diverse professional groups including
primary and secondary care health professionals and their associations, public health officials, non-governmental
associations, patients, asthma advocacy groups, and the general public. Each member will contribute according to his or
her expertise, resources and contacts. This may be done under the umbrella of national or local health societies or
professional or scientific organizations, or through initiatives such as the Global Initiative for Asthma (GINA) and the
Global Alliance against Chronic Respiratory Diseases (GARD).568 Knowledge translation specialists can be consulted to
ensure optimal evidence-based implementation methods. Ideally, a project coordinator should be involved.
Public health strategies involving a broad coalition of stakeholders in asthma care, including medical societies, health
care professionals, patient support groups, government, and the private sector, have been implemented in Australia,569
in the United States,570 and other countries.
TE
2. Assess the current status of care delivery, care gaps and current needs in the target area
PY
O
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D
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U
The working group should assess the current status of asthma care in the target country/region in terms of mortality and
morbidity, indicators of delivery of quality care and available resources for implementation. Processes for referral,
current care facilities and access to asthma medications, as well as the degree of understanding of the management
recommendations by practitioners/caregivers also need to be evaluated. Current ‘care gaps’ and their determinants565,571
should be identified and their respective consequences estimated. This will aid in setting priorities (Box A6-3) and
planning strategies that can fill the care gaps.
O
T
C
O
3. Select the material to be implemented, agree on main goals, identify key recommendations, and adapt them to
the local context or environment
M
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IA
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D
O
N
Once the material to be implemented has been selected (e.g. specific management recommendations from the GINA
report), the working group should determine if any of the material requires adaptation to the local/regional context and
environment. The working group should agree on realistic goals, and set priorities. Instruments such as the ADAPTE572
tool are available to guide the process of adaptation, including recommendations on planning and set-up, the adaptation
process, and the production of the final document.
TE
D
4. Identify barriers to, and facilitators of, implementation
C
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PY
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H
The next step is to identify barriers to, and facilitators of, implementation in the target country/region, and develop
appropriate strategies around this. In some areas, particularly in low-income countries, asthma may not be considered a
high priority health concern in comparison to other respiratory diseases like tuberculosis and pneumonia. In such areas,
practical asthma management strategies could include a simple algorithm for separating non-infectious from infectious
respiratory illnesses; simple objective measurements for diagnosis and management such as peak flow variability;
available, affordable and low-risk medications for achieving good asthma control; a simple process for recognizing
severe asthma; and simple diagnosis and management approaches relevant to the facilities and limited resources
available. Other local barriers such as the lack of availability of resources/medications, organizational problems, or
communication issues between caregivers should also be addressed (Box A6-3).
GINA Appendix Chapter 6. Implementing asthma management strategies in health systems
63
Box A6-3. Common asthma management care gaps
Management care gap
Barriers to reducing
the gap (examples)
Possible implementation
strategy
Process and outcome
measures
Over/under-diagnosis of
asthma
Lack of availability of
lung function tests
Identification of nearby lung
function facilities
% patients having lung
function tests
Inadequate assessment of
asthma control
Lack of knowledge of
criteria
Education/continuing medical Survey of use of criteria
eduction (CME)
Lack of assessment of
SABA use
Lack of direct
questioning
Automated letter based on
pharmacy dispensing
Number of canisters
dispensed per year
Insufficient environmental or Lack of time to explain
preventative measures
Increase access to educators; Survey implementation
involve patients as educators of intervention
Lack of individualized
pharmacotherapy
Insufficient knowledge
of guideline
Education/CME
Lack of education and
guided self-management
Lack of availability of
educators
Increase access to educators; % patients offered
involve patients as educators education
Absence of an asthma
action plan, or failure by
patients to use their action
plan
Not enough time to
produce and explain
the plan
Increase access to educators; % patients receiving
involve patients as
written asthma action
educators; provide clinicians plan
with templates
No assessment of patients’
skills with inhalers, PEF
Lack of time or
knowledge
Systematic assessment at
% patients in whom
visits; provide device-specific technique is checked
checklists
No assessment of
adherence to therapy
Not integrated into
practice
Reminders; sample wording
(see GINA report, Box 2-4);
automated pharmacy letter
% patients in whom
adherence is checked
No regular follow up;
discontinuity of care
Lack of follow-up
arrangements
Improved management
% patients having followup visit
Variable/insufficient access
to care; lack of availability
of asthma controllers
Insufficient resources
Increase resources; revise
process
Assess continuity of care
Organize joint sessions on
asthma care
Focus group assessing
this aspect of care
C
TE
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IB
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D
R
O
PY
C
O
T
O
N
D
O
LIA
ER
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H
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PY
Lack of willingness to
change
O
Poor communication
between various groups of
health care providers
Assessment of treatment
(e.g. audit)
Based on Boulet et al. A guide to the translation of the Global Initiative for Asthma (GINA) strategy into improved care.566
NOTE: These are considered important care gaps according to current guidelines and consensus, but for some, specific evidence of improvement in
asthma outcomes following their application is not yet available.
5. Select an implementation framework and its component strategies
The Knowledge to action model has been proposed as a framework for guideline implementation but other models can
also be considered.573 This framework allows a continuing circle of improvement and the integration of new
evidence/guidelines updates into the intervention process. Using this framework, a series of strategies can be proposed
based on their ability to address the previously identified care gaps and barriers. Box A6-4 lists examples of high-impact
interventions for asthma management. Quality of care improvements are made in progressive steps with regular
assessment of their performance.
64
GINA Appendix Chapter 6. Implementing asthma management strategies in health systems
Ideally, interventions should be conducted at the level of both the patient and the health care provider. Studies of the
most effective means of medical education show that it may be difficult to induce changes in clinical practice. However,
among the most effective methods are:
•
Reminders at the point of care
•
•
•
•
Automated letter to patient and/or prescriber based on pharmacy dispensing574,575
Interactive workshops
Audit and feedback
Multifaceted interventions. These include methods such as medical audit and feedback, reminders, local
consensus processes, marketing, and use of practice facilitators.576-580
Publications in journals that are associated with multidisciplinary symposia, workshops or conferences involving
national and local experts, along with involvement of the professional and mass media can help to communicate
key messages.
Embedding guidelines into electronic health records is promising,581,582 but a recent review showed the challenges
of developing integrated care pathways.583
•
U
TE
•
D
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IB
A useful resource for choosing the best implementation strategy is provided in the recommendations of the Cochrane
Effective Practice and Organization of Care Review Group.584
PY
O
R
Box A6-4 Examples of high-impact interventions in asthma management
AT
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D
O
N
O
T
C
O
• Optimized ICS use for patients with a recent hospital admission and/or severe asthma585
• Early treatment with ICS, guided self-management, reduction in exposure to tobacco smoke, improved
access to asthma education558
• Self-inking stamp prompting assessment of asthma control and treatment strategies586
• Use of individualized written asthma action plans as part of self-management education219
• An evidence-based care process model for acute and chronic pediatric asthma management,
implemented at multiple hospitals587
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ICS: inhaled corticosteroids
R
IG
PY
O
•
•
A planning phase: in which key recommendations are prioritized for the targeted population, and key messages,
main outcomes and actions to be taken are determined.
An assessment phase: to review uptake by the target group and the impact of interventions.
A monitoring and adjustment phase: in which outcomes selected for determination of the impact and sustainability
of the intervention are assessed, and interventions are adjusted based on the findings.
C
•
H
According to the Knowledge to action conceptual framework, the implementation process should include:
Potential new tools for implementation include internet-based programs, social networks and electronic tools, although
their effectiveness remains to be determined. In all cases, the messages must be simple, easily understood, practical
and implementable.
6. Develop a step-by-step implementation plan
Select target populations and outcomes
Efforts should be devoted to the entire asthma population, but particularly to ‘at-risk’ or ‘high-morbidity’ populations. This
includes patients with poor adherence to treatment or follow up; those who experience frequent exacerbations or
frequently use the health care system; adolescents; elderly patients; and those with socioeconomic, psychological,
psychosocial and economic problems.588-590 An alternative approach is to select a particular intervention and implement
GINA Appendix Chapter 6. Implementing asthma management strategies in health systems
65
this in a population that is already under care; for example, patients attending for another clinical problem could be
offered an asthma control assessment at that time.
Key outcomes and realistic targets should be identified, and the expected degree of change estimated (Box A6-5).
Box A6-5 Potential key outcomes and targets to consider for implementation programs
TE
Reduce asthma-related hospital admissions by 50% in the next 3 years16
Reduce emergency attendances (hospital and primary care) by 50% in the next 3 years
Reduce asthma mortality rates by 80% in the next 5 years
Have asthma control assessed in >80% of patients in the targeted population
Achieve good asthma control in >80% of the patient population
Ensure that >80% of patients with poor asthma control have had their medication optimized
Have written asthma action plans provided to >80% of patients with diagnosed asthma
Reduce acute health care costs related to asthma by 50%
R
IB
U
•
•
•
•
•
•
•
•
IS
T
Identify resources
O
R
D
Local support of implementation initiatives is essential, and funding should be identified at the level of governments,
funding agencies, medical or professional societies and industry.
PY
Set timelines
C
O
A specific agenda should be established, with timelines for roll-out and assessment of interventions.
N
O
T
Distribute tasks to members
AT
ER
IA
L-
D
O
Participants should understand their assigned tasks and agree with the agenda. The process could start on a small
scale with the most motivated people. Successes are a source of motivation for all, so it is helpful to initially select
interventions with the highest chance of success and with an achievable timeframe for their implementation (e.g. 3–6
months). Involvement of participants and their performance should be monitored.
M
Evaluate outcomes
R
IG
H
TE
D
An important part of the implementation process is to establish a means of evaluating the effectiveness of the program
and any improvements in quality of care. The Cochrane Effective Practice and Organization of Care Group (EPOC)
offers suggestions on how to assess the effectiveness of interventions.584
C
O
PY
Evaluation involves surveillance of traditional epidemiological parameters, such as morbidity and mortality, as well as
specific audits of both process and outcome within different sectors of the health care system. Each country should
determine its own minimum sets of data to audit health outcomes.
A variety of assessment tools are available to facilitate consistent and objective assessment of asthma morbidity and
asthma control in the target population.214 Recording the results of these assessments at each clinical visit can provide
the clinician with a long-term record of a patient’s response to their treatment. This type of direct feedback has several
benefits. It is a means for the patient and health care provider to become familiar with good versus poor control of
asthma (and to start to aim for the former); an indicator of changes in asthma control in response to changes in
treatment; and a reference point against which deteriorating asthma can be evaluated. Use of administrative datasets
(e.g. dispensing records) or urgent health care utilization can help to identify at-risk patients or to audit the quality of
health care. A strategy that includes providing health care providers with direct feedback about specific health care
results of their patients may be particularly important for general practitioners, who treat many diseases in addition to
asthma, and thus could not be expected to know every guideline in detail.
66
GINA Appendix Chapter 6. Implementing asthma management strategies in health systems
7. Continuously review progress and results to determine if the strategy requires modification
Following the initial evaluation of outcomes of the implementation program, the working party should determine whether
the strategies or initiatives need to be changed or improved. Methods should be established for ensuring that the
intervention can be sustained, and individuals who will be responsible for ensuring its continuity should be identified,
especially in terms of on-going financial and organizational support. Regular communications on the project’s impact on
asthma outcomes may help to maintain interest in the project and ensure continued resources.
ECONOMIC VALUE OF IMPLEMENTING MANAGEMENT RECOMMENDATIONS FOR ASTHMA CARE
D
R
O
GINA DISSEMINATION AND IMPLEMENTATION RESOURCES
IS
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TE
Cost is recognized as an important barrier to the delivery of optimal evidence-based health care in almost every country,
although its impact on patients’ access to treatment varies widely both between and within countries. At the country or
local level, health authorities make resource availability and allocation decisions that affect populations of asthma
patients by considering the balance and trade-offs between costs and clinical outcomes (benefits and harms), often in
the context of competing public health and medical needs. Treatment costs must also be explicitly considered at each
consultation between health care provider and patient to assure that cost does not present a barrier to achieving good
asthma control.585 Thus, those involved in the adaptation and implementation of asthma guidelines require an
understanding of both the cost and cost effectiveness of various management recommendations in asthma care.
C
O
PY
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IG
H
TE
D
M
AT
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IA
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D
O
N
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C
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Educational materials based on the Global Strategy for Asthma Management and Prevention are available in several
forms and can be found on the GINA Website (www.ginasthma.org).
GINA Appendix Chapter 6. Implementing asthma management strategies in health systems
67
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